Compositions and methods for increasing efficiency of cardiac metabolism

ABSTRACT

Compositions and methods for increasing efficiency of cardiac metabolism are provided.

This application claims the benefit of, and priority to, U.S.Provisional Patent Application No. 62/647,926, filed Mar. 26, 2018, U.S.Provisional Patent Application No. 62/637,434, filed Mar. 2, 2018, U.S.Provisional Patent Application No. 62/710,316, filed Feb. 16, 2018, U.S.Provisional Patent Application No. 62/524,237, filed Jun. 23, 2017, andU.S. Provisional Patent Application No. 62/522,214, filed Jun. 20, 2017,the contents of each of which are incorporated by reference.

FIELD OF THE INVENTION

This application is related to compositions and methods for increasingthe efficiency of cardiac metabolism.

BACKGROUND

Heart disease is the leading cause of death worldwide, accounting for 15million deaths across the globe in 2015. In many forms of heart disease,decreased cardiac efficiency stems from changes in mitochondrial energymetabolism. Mitochondria are sub-cellular compartments in whichmetabolites derived from glucose and fatty acids are oxidized to producehigh-energy molecules. Increasing fatty acid oxidation in the heartdecreases glucose oxidation, and vice versa. Glucose oxidation is a moreefficient source of energy, but in certain types of heart disease, suchas heart failure, ischemic heart disease, and diabetic cardiomyopathies,fatty acid oxidation predominates in cardiac mitochondria. As a result,the pumping capacity of the heart is reduced.

Existing drugs that redress the balance between glucose oxidation andfatty acid oxidation in cardiac mitochondria have serious shortcomings.Foremost among them is that such drugs address only part of the problem:the reliance on fatty acid oxidation in lieu of glucose oxidation causesa 10% reduction in efficiency in energy production, but patients withheart disease often show a decrease in cardiac efficiency of up to 30%.Consequently, existing approaches to improve cardiac function byaltering mitochondrial metabolism are unsatisfactory, and millions ofpeople continue to die from heart disease each year.

SUMMARY

The invention provides compositions that stimulate cardiac glucoseoxidation and mitochondrial respiration. The compositions include acompound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation, such as trimetazidine, and a compound that promotesmitochondrial respiration, such as succinate. The compositions may alsoinclude a molecule, such as nicotinic acid, that serves as a precursorfor synthesis of nicotinamide adenine dinucleotide (NAD⁺), which alsofacilitates mitochondrial respiration. Preferably, the compositionsinclude compounds in which a trimetazidine derivative, succinate, and,optionally, a NAD⁺ precursor are covalently linked in a single molecule.Such compounds can be metabolized in the body to allow the individualcomponents to exert distinct biochemical effects to increase glucoseoxidation relative to fatty acid oxidation and improve overallmitochondrial respiration in the heart. The invention also providesmethods of altering cardiac metabolism by providing compounds of theinvention.

Because the compositions concomitantly shift cardiac metabolism towardglucose oxidation and increase mitochondrial respiration, they areuseful as therapeutic agents for treating heart diseases characterizedby elevated fatty acid oxidation, such as heart failure, ischemic heartdisease, and diabetic cardiomyopathies. By shifting cardiac metabolismfrom fatty acid oxidation to glucose oxidation, the compositions allowthe use of a more efficient source of energy. In addition, thecompositions stimulate metabolic pathways that are common to oxidationof both glucose and fatty acids and that may also be impaired inpatients with heart disease. Some compositions of the invention includea compound that comprises trimetazidine covalently coupled to one ormore activators of mitochondrial respiration.

Furthermore, trimetazidine can cause Parkinsonian symptoms for a portionof the population. Without being limited by any particular theory ormechanism of action, it is also believed that delivery of trimetazidineas a component of a larger molecule may improve its efficacy andmitigate its side effects.

In an aspect, the invention includes compounds represented by formula(I):

A-L-B  (I),

in which A is a compound that shifts cardiac metabolism from fatty acidoxidation to glucose oxidation, L is a linker, and B is a compound thatpromotes mitochondrial respiration.

The compound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation may be trimetazidine, etomoxir, perhexiline, a PPARagonist, a malonyl CoA decarboxylase inhibitor, or dichloroacetate.

The compound that promotes mitochondrial respiration may be anintermediate of the citric acid cycle or a molecule that can bemetabolized to enter the citric acid cycle. For example, the compoundmay be succinate, fumarate, malate, oxaloacetate, citrate, isocitrate,α-ketoglutarate, pyruvate, acetone, acetoacetic acid, β-hydroxybutyricacid, β-ketopentanoate, or β-hydroxypentanoate.

The linker may be any suitable linker that can be cleaved in vivo. Thelinker may be an alkoxy group. The linker may be polyethylene glycol ofany length. Preferably, the linker is represented by (CH₂CH₂O)_(x), inwhich x=1-15.

The compound may include a NAD⁺ precursor molecule covalently linked toanother component of the compound. The NAD⁺ precursor molecule may benicotinic acid, nicotinamide, or nicotinamide riboside. The NAD⁺precursor molecule may be attached to the compound that shifts cardiacmetabolism, the compound that promotes mitochondrial respiration, or thelinker. The NAD⁺ precursor molecule may be attached to another componentvia an additional linker. Preferably, the NAD⁺ precursor molecule isattached to the compound that promotes mitochondrial respiration via a1,3-propanediol linkage.

The compound of formula (I) may be represented by formula (II):

in which y=1-3.

The compound of formula (I) may be represented by formula (III):

in which y=1-3.

In another aspect, the invention includes a compound represented byformula (IV):

in which R¹, R², and R³ are independently H or a (C₁-C₄)alkyl group; R⁴and R⁵ together are ═O, —O(CH₂)_(m)O—, or —(CH₂)_(m)—, in which m=2-4,or R⁴ is H and R⁵ is OR¹⁴, SR¹⁴, or (CH₂CH₂O)_(n)H, in which R¹⁴ is H ora (C₁-C₄)alkyl group and n=1-15; and R⁶ is a single or multi-ringstructure optionally substituted at one or more ring positions by aheteroatom, in which each ring position optionally comprises one or moresubstituents.

One or more ring position of R⁶ may include a substituent that includesa compound that promotes mitochondrial respiration, such as succinate,fumarate, malate, oxaloacetate, citrate, isocitrate, α-ketoglutarate,pyruvate, acetone, acetoacetic acid, β-hydroxybutyric acid,β-ketopentanoate, or β-hydroxypentanoate. The substituent may include alinker, such as (CH₂CH₂O)_(x), in which x=1-15. The substituent mayinclude a NAD⁺ precursor molecule, such as nicotinic acid, nicotinamide,and nicotinamide riboside.

The substituent on a ring position of R⁶ may be

in which y=1-3.

The substituent on a ring position of R⁶ may be

in which y=1-3.

R⁶ may be

The compound of formula (IV) may have a structure represented formula(IX) or formula (X):

In another aspect, the invention includes compounds represented byformula (V):

in which R¹, R², and R³ are independently H or a (C₁-C₄)alkyl group; R⁴and R⁸ together are ═O, —O(CH₂)_(m)O—, or —(CH₂)_(m), in which m=2-4, orR⁴ is H and R⁸ is H, OR¹⁴, SR¹⁴, or (CH₂CH₂O)_(n)H, in which R¹⁴ is H ora (C₁-C₄)alkyl group and n=1-15; R⁹, R¹⁰, R¹², and R¹³ are independentlyH or (CH₂CH₂O)_(z)H, in which z=1-6; and R¹¹ comprises a compound thatpromotes mitochondrial respiration.

The compound that promotes mitochondrial respiration may be anintermediate of the citric acid cycle or a molecule that can bemetabolized to enter the citric acid cycle. For example, the compoundmay be succinate, fumarate, malate, oxaloacetate, citrate, isocitrate,α-ketoglutarate, pyruvate, acetone, acetoacetic acid, β-hydroxybutyricacid, β-ketopentanoate, or β-hydroxypentanoate.

R¹¹ may include a linker, such as polyethylene glycol. For example, R¹¹may include (CH₂CH₂O)_(x), in which x=1-15.

R¹¹ may be

in which y=1-3.

R¹¹ may include a NAD⁺ precursor molecule. For example, R¹¹ may includenicotinic acid, nicotinamide, or nicotinamide riboside.

R¹¹ may be

in which y=1-3.

In an aspect, the invention includes compounds represented by formula(VII):

A-C  (VII),

in which A is a compound that shifts cardiac metabolism from fatty acidoxidation to glucose oxidation, and C is a NAD⁺ precursor molecule. Aand C may be covalently linked.

The compound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation may be trimetazidine, etomoxir, perhexiline, a PPARagonist, a malonyl CoA decarboxylase inhibitor, or dichloroacetate.

The compound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation may be PEGylated with an ethylene glycol moiety. Thecompound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation may have multiple ethylene glycol moieties, such asone, two three, four, five, or more ethylene glycol moieties. Theethylene glycol moiety may be represented by (CH₂CH₂O)_(x), in whichx=1-15. The ethylene glycol moiety may form a covalent linkage betweenthe compound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation and the NAD⁺ precursor molecule. The ethylene glycolmoiety may be separate from a covalent linkage between the compound thatshifts cardiac metabolism from fatty acid oxidation to glucose oxidationand the NAD⁺ precursor molecule. The compound that shifts cardiacmetabolism from fatty acid oxidation to glucose oxidation may be aPEGylated form of trimetazidine.

The NAD⁺ precursor molecule may be nicotinic acid, nicotinamide, ornicotinamide riboside.

The compound of formula (VII) may include nicotinic acid that iscovalently linked to a PEGylated form of trimetazidine. The nicotinicacid may be covalently linked via the PEGylated moiety, i.e., via anethylene glycol linkage. The nicotinic acid may be covalently linked viathe trimetazidine moiety.

The compound of formula (VII) may have a structure represented byformula (X), as shown above.

In an aspect, the invention includes compounds represented by formula(VIII):

A-L-C  (VIII),

in which A is a compound that shifts cardiac metabolism from fatty acidoxidation to glucose oxidation, L is a linker, and C is a NAD⁺ precursormolecule. A may be covalently linked to L, and L may be covalentlylinked to C.

The compound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation, the linker, and the NAD⁺ precursor molecule may be asdescribed above in relation to compounds of other formulas.

The compound of formula (VIII) may have a structure represented byformula (X), as shown above.

Any of the compounds described above may include one or more atoms thatare enriched for an isotope. For example, the compounds may have one ormore hydrogen atoms replaced with deuterium or tritium. The isotopicallyenriched atom or atoms may be located at any position within thecompound.

In an aspect, the invention includes compositions that include at leasttwo of A, B, and C, in which A is a compound that shifts cardiacmetabolism from fatty acid oxidation to glucose oxidation as describedabove, B is a compound that promotes mitochondrial respiration asdescribed above, and C is a NAD⁺ precursor molecule as described above.The compositions may include A, B, and C. Each of components A, B, and Cmay be provided as a separate molecule, or two or more of the componentsmay be covalently linked in a single molecule. For example, components Aand B may be covalently linked in a single molecule, and C may beprovided as a separate molecule.

The compositions may include co-crystals of two or more separatemolecules that include two or more of components A, B, and C. Forexample, a co-crystal may include (1) a compound of formula (I), (III),(IV), or (V) and (2) nicotinic acid, nicotinamide, or nicotinamideriboside. Preferably the co-crystal includes nicotinamide.

In an aspect, the invention includes methods of increasing efficiency ofcardiac metabolism in a subject. The methods include providing acompound represented by formula (I), as described above. In the methods,the compound of formula (I) may include any of the features describedabove in relation to compounds of the invention.

In an aspect, the invention includes methods of increasing efficiency ofcardiac metabolism in a subject. The methods include providing acompound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation, a compound that promotes mitochondrial respiration,and, optionally, a compound that is a NAD⁺ precursor molecule.

The compound that shifts cardiac metabolism from fatty acid oxidation toglucose may be trimetazidine, etomoxir, perhexiline, a PPAR agonist, amalonyl CoA decarboxylase inhibitor, or dichloroacetate.

The compound that promotes mitochondrial respiration may be anintermediate of the citric acid cycle or a molecule that can bemetabolized to enter the citric acid cycle, such as succinate, fumarate,malate, oxaloacetate, citrate, isocitrate, α-ketoglutarate, pyruvate,acetone, acetoacetic acid, β-hydroxybutyric acid, β-ketopentanoate, orβ-hydroxypentanoate.

The NAD⁺ precursor molecule may be nicotinic acid, nicotinamide, ornicotinamide riboside.

The compounds may be provided in any suitable manner. The compounds maybe provided in a single composition. Alternatively, the compounds maynot be provided in a single composition. For example, one or two of thecompounds may be provided in a single composition, and another compoundmay be provided in a separate composition. Alternatively, each compoundmay be provided in a separate composition. The compounds may be providedsimultaneously or sequentially. The compounds may be provided atdifferent intervals, with different frequency, or in differentquantities.

It is believed that any disease that may be treated using trimetazidinewould benefit from compounds of the invention as described herein withmore efficacious results and fewer side effects. Exemplary diseases arethose that involve impaired mitochondrial function or altered fatty acidoxidation, such as heart failure diseases, cardiac dysfunction diseases,or muscle myopathy diseases. Exemplary methods involve providing acomposition as described herein or any combination of a compound thatshifts cardiac metabolism from fatty acid oxidation to glucosemetabolism, a compound that promotes mitochondrial respiration, and/oroptionally an NAD⁺ precursor molecule.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a table summarizing the effects of various compounds onmitochondrial function.

FIG. 2 is a table summarizing the effects of nicotinamide on variousmitochondrial functional parameters.

FIG. 3 is a series of graphs showing the effects of nicotinamide onoxygen consumption rate and reserve capacity.

FIG. 4 is a series of graphs showing the effects of nicotinamide onextracellular acidification rate.

FIG. 5 is a table summarizing the effects of a combination oftrimetazidine and nicotinamide on various mitochondrial functionalparameters.

FIG. 6 is a series of graphs showing the effects of a combination oftrimetazidine and nicotinamide on oxygen consumption rate and reservecapacity.

FIG. 7 is a series of graphs showing the effects of a combination oftrimetazidine and nicotinamide on extracellular acidification rate.

FIG. 8 is a table summarizing the effects of succinate on variousmitochondrial functional parameters.

FIG. 9 is a series of graphs showing the effects of succinate on oxygenconsumption rate and reserve capacity.

FIG. 10 is a series of graphs showing the effects of succinate onextracellular acidification rate.

FIG. 11 is a table summarizing the effects of compound CV-8816 onvarious mitochondrial functional parameters.

FIG. 12 is a series of graphs showing the effects of compound CV-8816 onoxygen consumption rate and reserve capacity.

FIG. 13 is a series of graphs showing the effects of compound CV-8816 onextracellular acidification rate.

FIG. 14 is a table summarizing the effects of compound CV-8814 onvarious mitochondrial functional parameters.

FIG. 15 is a series of graphs showing the effects of compound CV-8814 onoxygen consumption rate and reserve capacity.

FIG. 16 is a series of graphs showing the effects of compound CV-8814 onextracellular acidification rate.

FIG. 17 is a table summarizing the effects of trimetazidine on variousmitochondrial functional parameters.

FIG. 18 is a series of graphs showing the effects of trimetazidine onoxygen consumption rate and reserve capacity.

FIG. 19 is a series of graphs showing the effects of trimetazidine onextracellular acidification rate.

FIG. 20 is a table summarizing the effects of compound CV-8815 onvarious mitochondrial functional parameters.

FIG. 21 is a series of graphs showing the effects of compound CV-8815 onoxygen consumption rate and reserve capacity.

FIG. 22 is a series of graphs showing the effects of compound CV-8815 onextracellular acidification rate.

FIG. 23 is a table summarizing the effects of a combination ofsuccinate, nicotinamide, and trimetazidine on various mitochondrialfunctional parameters.

FIG. 24 is a series of graphs showing the effects of a combination ofsuccinate, nicotinamide, and trimetazidine on oxygen consumption rateand reserve capacity.

FIG. 25 is a series of graphs showing the effects of a combination ofsuccinate, nicotinamide, and trimetazidine on extracellularacidification rate.

FIG. 26 is a table summarizing the effects of a combination oftrimetazidine analog 2 and nicotinamide on various mitochondrialfunctional parameters.

FIG. 27 is a series of graphs showing the effects of a combination oftrimetazidine analog 2 and nicotinamide on oxygen consumption rate andreserve capacity.

FIG. 28 is a series of graphs showing the effects a combination oftrimetazidine analog 2 and nicotinamide on extracellular acidificationrate.

FIG. 29 is a table summarizing the effects of a combination oftrimetazidine analog 1 and nicotinamide on various mitochondrialfunctional parameters.

FIG. 30 is a series of graphs showing the effects of a combination oftrimetazidine analog 1 and nicotinamide on oxygen consumption rate andreserve capacity.

FIG. 31 is a series of graphs showing the effects of a combination oftrimetazidine analog 1 and nicotinamide on extracellular acidificationrate.

FIG. 32 is a table summarizing the effects of a combination oftrimetazidine analog 3 and nicotinamide on various mitochondrialfunctional parameters.

FIG. 33 is a series of graphs showing the effects of a combination oftrimetazidine analog 3 and nicotinamide on oxygen consumption rate andreserve capacity.

FIG. 34 is a series of graphs showing the effects of a combination oftrimetazidine analog 3 and nicotinamide on extracellular acidificationrate.

FIG. 35 is a table summarizing the effects of a combination of succinateand nicotinamide on various mitochondrial functional parameters.

FIG. 36 is a series of graphs showing the effects of a combination ofsuccinate and nicotinamide on oxygen consumption rate and reservecapacity.

FIG. 37 is a series of graphs showing the effects of a combination ofsuccinate and nicotinamide on extracellular acidification rate.

FIG. 38 is a schematic of the ischemia-reperfusion (IR) method used toanalyze the effects of compositions of the invention on coronary flow.

FIG. 39 is a graph of coronary flow of after IR.

FIG. 40 is graph of left ventricular developed pressure (LVDP) after IR.

FIG. 41 shows images of TTC-stained heart slices after IR.

FIG. 42 is graph of infarct size after IR.

FIG. 43 is a schematic of the method used to analyze the effects ofcompositions of the invention on cardiac function.

FIG. 44 shows hearts from mice six weeks after transverse aorticconstriction.

FIG. 45 is of graph of heart weight relative to body weight six weeksafter transverse aortic constriction.

FIG. 46 is graph of heart weight six weeks after transverse aorticconstriction.

FIG. 47 shows graphs of fractional shortening (FS) and ejection fraction(EF) at indicated time points after transverse aortic constriction.

FIG. 48 is a graph of left ventricular end-systolic diameter atindicated time points after transverse aortic constriction.

FIG. 49 is a graph of intraventricular septal dimension at indicatedtime points after transverse aortic constriction.

FIG. 50 is a graph of left ventricular mass at indicated time pointsafter transverse aortic constriction.

FIG. 51 is a graph of isovolumic relaxation time at indicated timepoints after transverse aortic constriction.

FIG. 52 is a graph of the ratio peak velocity flow in early diastole vs.late diastole at indicated time points after transverse aorticconstriction.

FIG. 53 is a graph of left ventricular developed pressure at six weeksafter transverse aortic constriction.

FIG. 54 is a graph of the rate of left ventricle pressure rise at sixweeks after transverse aortic constriction.

FIG. 55 is a graph showing levels of CV-8814 and trimetazidine afterintravenous administration of CV-8834.

FIG. 56 is a graph showing levels of CV-8814 and trimetazidine afteroral administration of CV-8834.

FIG. 57 is a graph showing levels of CV-8814 and trimetazidine afteroral administration of CV-8834.

FIG. 58 is a graph showing levels of CV-8814 and trimetazidine afteroral administration of CV-8834.

FIG. 59 is a graph showing levels of CV-8814 and trimetazidine afteroral administration of CV-8834.

FIG. 60 is a graph showing levels of trimetazidine after oraladministration of CV-8972 or intravenous administration oftrimetazidine.

FIG. 61 is a graph showing levels of CV-8814 after oral administrationof CV-8972 or intravenous administration of CV-8814.

FIG. 62 is a graph showing levels of CV-8814 after intravenousadministration of CV-8834 or oral administration of CV-8834.

FIG. 63 is a graph showing levels of CV-8814 after intravenousadministration of CV-8814 or oral administration of CV-8814.

FIG. 64 is a graph showing the HPLC elution profile of a batch ofCV-8972.

FIG. 65 is a graph showing analysis of molecular species present in abatch of CV-8972.

FIG. 66 is a pair of graphs showing HPLC elution profiles of molecularspecies present in a batch of CV-8972.

FIG. 67 is a pair of graphs showing HPLC elution profiles of molecularspecies present in a batch of CV-8972.

FIG. 68 is a graph showing X-ray powder diffraction analysis of a batchof CV-8972.

FIG. 69 is a graph showing X-ray powder diffraction analysis of batchesof CV-8972.

FIG. 70 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of a batch of CV-8972.

FIG. 71 is a graph showing dynamic vapor sorption (DVS) of a batch ofCV-8972.

FIG. 72 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of a batch of CV-8972.

FIG. 73 is a graph showing dynamic vapor sorption (DVS) of a batch ofCV-8972.

FIG. 74 is a graph showing X-ray powder diffraction analysis of samplesof CV-8972.

FIG. 75 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of a batch of CV-8972.

FIG. 76 is a graph showing X-ray powder diffraction analysis of samplesof CV-8972.

FIG. 77 is a graph showing X-ray powder diffraction analysis of samplesof CV-8972.

FIG. 78 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of samples containing form A of CV-8972.

FIG. 79 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of a sample containing form A of CV-8972.

DETAILED DESCRIPTION

The invention provides compositions that increase the efficiency ofcardiac metabolism by concomitantly shifting cardiac metabolism fromfatty acid oxidation to glucose oxidation and increasing mitochondrialrespiration. Glucose oxidation and fatty acid oxidation areenergy-producing metabolic pathways that compete with each other forsubstrates. In glucose oxidation, glucose is broken down to pyruvate viaglycolysis in the cytosol of the cell. Pyruvate then enters themitochondria, where it is converted to acetyl coenzyme A (acetyl-CoA).In beta-oxidation of fatty acids, which occurs in the mitochondria,two-carbon units from long-chain fatty acids are sequentially convertedto acetyl-CoA.

The remaining steps in energy production from oxidation of glucose orfatty acids are common to the two pathways. Acetyl-CoA is oxidized tocarbon dioxide (CO₂) via the citric acid cycle, which results in theconversion of nicotinamide adenine dinucleotide (NAD⁺) to its reducedform, NADH. NADH, in turn, drives the mitochondrial electron transportchain. The electron transport chain comprises a series of fourmitochondrial membrane-bound complexes that transfer electrons via redoxreactions and pump protons across the membrane to create a protongradient. The redox reactions of the electron transport chain requiremolecular oxygen (O₂). Finally, the proton gradient enables anothermembrane-bound enzymatic complex to form high-energy ATP molecules, thesource of energy for most cellular reactions.

In many types of heart disease, the overall efficiency of energyproduction by cardiac mitochondria is diminished. In part, this is dueto an increased reliance on fatty acid oxidation over glucose oxidationin many types of heart disease. Glucose oxidation is a more efficientpathway for energy production, as measured by the number of ATPmolecules produced per O₂ molecule consumed, than is fatty acidoxidation. However, other metabolic changes contribute to decreasedcardiac efficiency in patients with heart disease. For example, overallmitochondrial oxidative metabolism can be impaired in heart failure, andenergy production is decreased in ischemic heart disease due to alimited supply of oxygen. As indicated above, the final steps in ATPsynthesis, which include several redox reactions and oxygen-drivenproton transport, are common to both the glucose oxidation and fattyacid oxidation pathways. Thus, shifting the balance from fatty acidoxidation to glucose oxidation by itself is not enough in manycircumstances to restore full cardiac efficiency because downstreamprocesses are affected as well.

The invention provides compositions that improve cardiac efficiency byusing multiple mechanisms to alter mitochondrial metabolism. Byincluding a component that shifts cardiac metabolism from fatty acidoxidation to glucose oxidation and one or more other components thatpromote mitochondrial respiration, the compositions trigger a change inthe pathway used to produce energy and concomitantly improve overallmitochondrial oxidative function. Consequently, the compositions of theinvention are more effective at restoring cardiac capacity in patientswith heart disease, such as heart failure, ischemic heart disease, anddiabetic cardiomyopathies, than are compounds that only effect a shiftto glucose oxidation.

In some embodiments, the compositions are compounds represented byformula (I):

A-L-B  (I),

in which A is a compound that shifts cardiac metabolism from fatty acidoxidation to glucose oxidation, L is a linker, and B is a compound thatpromotes mitochondrial respiration.

Component A may be any suitable compound that shifts cardiac metabolismfrom fatty acid oxidation to glucose oxidation. Such compounds can beclassified based on their mechanism of action. See Fillmore, N., et al.,Mitochondrial fatty acid oxidation alterations in heart failure,ischemic heart disease and diabetic cardiomyopathy, Brit. J. Pharmacol.171:2080-2090 (2014), incorporated herein by reference.

One class of glucose-shifting compounds includes compounds that inhibitfatty acid oxidation directly. Compounds in this class includeinhibitors of malonyl CoA decarboxylase (MCD), carnitine palmitoyltransferase 1 (CPT-1), or mitochondrial fatty acid oxidation.Mitochondrial fatty acid oxidation inhibitors include trimetazidine andother compounds described in WO 2002/064576, which is incorporatedherein by reference. Trimetazidine binds to distinct sites on the innerand outer mitochondrial membranes and affects both ion permeability andmetabolic function of mitochondria. Morin, D., et al., Evidence for theexistence of [³H]-trimetazidine binding sites involved in the regulationof the mitochondrial permeability transition pore, Brit. J. Pharmacol.123:1385-1394 (1998), incorporated herein by reference. MCD inhibitorsinclude CBM-301106, CBM-300864, CBM-301940,5-(1,1,1,3,3,3-hexafluoro-2-hydroxypropan-2-yl)-4,5-dihydroisoxazole-3-carboxamides,methyl5-(N-(4-(1,1,1,3,3,3-hexafluoro-2-hydroxypropan-2-yl)phenyl)morpholine-4-carboxamido)pentanoate,and other compounds described in Chung, J. F., et al., Discovery ofPotent and Orally Available Malonyl-CoA Decarboxylase Inhibitors asCardioprotective Agents, J. Med. Chem. 49:4055-4058 (2006); Cheng J. F.et al., Synthesis and structure-activity relationship of small-moleculemalonyl coenzyme A decarboxylase inhibitors, J. Med. Chem. 49:1517-1525(2006); US Publication No. 2004/0082564; and WO 2002/058698, which areincorporated herein by reference. CPT-1 inhibitors include oxfenicine,perhexiline, etomoxir, and other compounds described in WO 2015/018660,WO 2008/109991; WO 2009/015485; US Publication No. 2011/0212072; and WO2009/156479, which are incorporated herein by reference.

Another class of glucose-shifting compounds includes compounds thatstimulate glucose oxidation directly. Examples of such compounds aredescribed in US Publication No. 2003/0191182; WO 2006/117686; U.S. Pat.No. 8,202,901, which are incorporated herein by reference.

Another class of glucose-shifting compounds includes compounds thatdecrease the level of circulating fatty acids that supply the heart.Examples of such compounds include agonists of PPARα and PPARγ,including fibrate drugs, such as clofibrate, gemfibrozil, ciprofibrate,bezafibrate, and fenofibrate, and thiazolidinediones, GW-9662, and othercompounds described in U.S. Pat. No. 9,096,538, which is incorporatedherein by reference.

Component L may be any suitable linker. Preferably, the linker can becleaved in vivo to release components A and B. The linker may be analkoxy group. The linker may be polyethylene glycol of any length. Thelinker may be represented by (CH₂CH₂O)_(x), in which x=1-15 or(CH₂CH₂O)_(x), in which x=1-3. Other suitable linkers include1,3-propanediol, diazo linkers, phosphoramidite linkers, disulfidelinkers, cleavable peptides, iminodiacetic acid linkers, thioetherlinkers, and other linkers described in Leriche, G., et al., Cleavablelinkers in chemical biology, Bioorg. Med. Chem. 20:571-582 (2012); WO1995000165; and U.S. Pat. No. 8,461,117, which are incorporated hereinby reference.

Component B may be any compound that promotes mitochondrial respiration.For example, component B may be an intermediate of the citric acid cycleor a molecule that can be metabolized to enter the citric acid cycle,such as succinate, fumarate, malate, oxaloacetate, citrate, isocitrate,α-ketoglutarate, pyruvate, acetone, acetoacetic acid, β-hydroxybutyricacid, β-ketopentanoate, or β-hydroxypentanoate. Intermediates of thecitric acid cycle may become depleted if these molecules are used forbiosynthetic purposes, resulting in inefficient generation of ATP fromthe citric acid cycle. However, due to the anaplerotic effect, providingone intermediate of the citric acid cycle leads to restoration of allintermediates as the cycle turns. Thus, intermediates of the citric acidcycle can promote mitochondrial respiration.

The compound may include a NAD⁺ precursor molecule. NAD⁺ is an importantoxidizing agent that acts as a coenzyme in multiple reactions of thecitric acid cycle. In these reactions, NAD⁺ is reduced to NADH.Conversely, NADH is oxidized back to NAD⁺ when it donates electrons tomitochondrial electron transport chain. In humans, NAD⁺ can besynthesized de novo from tryptophan, but not in quantities sufficient tomeet metabolic demands. Consequently, NAD⁺ is also synthesized via asalvage pathway, which uses precursors that must be supplied from thediet. Among the precursors used by the salvage pathway for NAD⁺synthesis are nicotinic acid, nicotinamide, and nicotinamide riboside.By providing a NAD⁺ precursor, such as nicotinic acid, nicotinamide, ornicotinamide riboside, the compound facilitates NAD⁺ synthesis.

The inclusion of a NAD⁺ precursor in compounds of the invention allowsthe compounds to stimulate energy production in cardiac mitochondria inmultiple ways. First, component A shifts cardiac metabolism from fattyacid oxidation to glucose oxidation, which is inherently more efficient.Next, component B ensures that the intermediates of the citric acidcycle are present at adequate levels and do not become depleted orlimiting. As a result, glucose-derived acetyl CoA is efficientlyoxidized. Finally, the NAD⁺ precursor provides an essential coenzymethat cycles between oxidized and reduced forms to promote respiration.In the oxidized form, NAD⁺ drives reactions of the citric acid cycle. Inthe reduced form, NADH promotes electron transport to create a protongradient that enables ATP synthesis. Consequently, the chemicalpotential resulting from oxidation of acetyl CoA is efficientlyconverted to ATP that can be used for various cellular functions.

The NAD⁺ precursor molecule may be covalently attached to the compoundin any suitable manner. For example, it may linked to A, L, or B, and itmay be attached directly or via another linker. Preferably, it isattached via a linker that can be cleaved in vivo. The NAD⁺ precursormolecule may be attached via a 1,3-propanediol linkage.

The compound may be covalently attached to one or more molecules ofpolyethylene glycol (PEG), i.e., the compound may be PEGylated. In manyinstances, PEGylation of molecules reduces their immunogenicity, whichprevents the molecules from being cleared from the body and allows themto remain in circulation longer. The compound may contain a PEG polymerof any size. For example, the PEG polymer may have from 1-500 (CH₂CH₂O)units. The PEG polymer may have any suitable geometry, such as astraight chain, branched chain, star configuration, or combconfiguration. The compound may be PEGylated at any site. For example,the compound may be PEGylated on component A, component B, component L,or, if present, the NAD⁺ precursor. The compound may be PEGylated atmultiple sites. For a compound PEGylated at multiple sites, the variousPEG polymers may be of the same or different size and of the same ordifferent configuration.

The compound may be a PEGylated form of trimetazidine. For example, thecompound may be represented by formula (VI):

in which one or more of the carbon atoms at positions A, B, C, D, and Eand/or the nitrogen atom at position F are substituted with—(CH₂CH₂O)_(n)H and n=1-15. The carbon atoms at positions A, B, C, D,and E may have two PEG substituents. In molecules that have multiple PEGchains, the different PEG chains may have the same or different length.

The compounds of formula (I) may be represented by formula (II):

in which y=1-3.

The compounds of formula (I) may be represented by formula (III):

in which y=1-3.

The invention also provides compounds represented by formula (IV):

in which R¹, R², and R³ are independently H or a (C₁-C₄)alkyl group; R⁴and R⁵ together are ═O, —O(CH₂)_(m)O—, or —(CH₂)_(m)—, in which m=2-4,or R⁴ is H and R⁵ is OR¹⁴, SR¹⁴, or (CH₂CH₂O)_(n)H, in which R¹⁴ is H ora (C₁-C₄)alkyl group and n=1-15; and R⁶ is a single or multi-ringstructure optionally substituted at one or more ring positions by aheteroatom, in which each ring position optionally comprises one or moresubstituents.

R⁶ may be a single or multi-ring structure of any size. For example, thestructure may contain 3-22 atoms, not including hydrogen atoms bonded toatoms in ring positions. The structure may include one or more alkyl,alkenyl, or aromatic rings. The structure may include one or moreheteroatoms, i.e., atoms other than carbon. For example, the heteroatommay be oxygen, nitrogen, or sulfur, or phosphorus.

One or more ring position of R⁶ may include a substituent that includesa compound that promotes mitochondrial respiration, as described abovein relation to component B of formula (I). The substituent may include alinker, as described above in relation to component L of formula (I).The substituent may include a NAD⁺ precursor molecule, as describedabove in relation to compounds of formula (I).

The substituent on a ring position of R⁶ may be

in which y=1-3.

The substituent on a ring position of R⁶ may be

in which y=1-3.

R⁶ may be

For some compounds of the invention that include trimetazidine prodrugs,analogs, deriviatives, it is advantageous to have the trimetazidinemoiety substituted with a single ethylene glycol moiety. Thus, preferredcompositions of the invention include compounds of formulas (I) and(VIII) that contain linkers in which x=1, compounds of formulas (II) and(III) in which y=1, compounds of formula (V) in which z=1, compounds offormula (VI) in which n=1, and compounds of formula (VII) in which A islinked to C via a single ethylene glycol moiety. Without wishing to bebound by theory, the attachment of a single ethylene glycol moiety tothe trimetazidine moiety may improve the bioavailability oftrimetazidine.

The compound of formula (IV) may have structure represented by formula(IX) or formula (X):

The invention also provides compounds represented by formula (V):

in which R¹, R², and R³ are independently H or a (C₁-C₄)alkyl group; R⁴and R⁸ together are ═O, —O(CH₂)_(m)O—, or —(CH₂)_(m), in which m=2-4, orR⁴ is H and R⁸ is H, OR¹⁴, SR¹⁴, or (CH₂CH₂O)_(n)H, in which R¹⁴ is H ora (C₁-C₄)alkyl group and n=1-15; R⁹, R¹⁰, R¹², and R¹³ are independentlyH or (CH₂CH₂O)_(z)H, in which z=1-15; and R¹¹ comprises a compound thatpromotes mitochondrial respiration, as described above in relation tocomponent B of formula (I). R¹¹ may include a linker, as described abovein relation to component L of formula (I).

R¹¹ may be

in which y=1-3.

R¹¹ may include a NAD⁺ precursor molecule, as described above inrelation to compounds of formula (I).

R¹¹ may be

in which y=1-3.

In some embodiments described above, compounds of the invention includemultiple active agents joined by linkers in a single molecule. It may beadvantageous to deliver multiple active agents as components of a singlemolecule. Without wishing to be bound by a particular theory, there areseveral reasons why co-delivery of active agents in a single moleculemay be advantageous. One possibility is that a single large molecule mayhave reduced side effects compared to the component agents. Freetrimetazidine causes symptoms similar to those in Parkinson's disease ina fraction of patients. However, when trimetazidine is derivatized toinclude other components, such as succinate, the molecule is bulkier andmay not be able to access sites where free trimetazidine can causesunintended effects. Trimetazidine derivatized as described above is alsomore hydrophilic and thus may be less likely to cross the blood-brainbarrier to cause neurological effects. Another possibility is thatmodification of trimetazidine may alter its pharmacokinetic properties.Because the derivatized molecule is metabolized to produce the activeagent, the active agent is released gradually. Consequently, levels ofthe active agent in the body may not reach peaks as high as when acomparable amount is administered in a single bolus. Another possibilityis that less of each active agent, such as trimetazidine, is requiredbecause the compounds of the invention include multiple active agents.For example, trimetazidine shifts metabolism from fatty acid oxidationto glucose oxidation, and succinate improves mitochondrial respirationgenerally. Thus, a compound that provides both agents stimulates alarger increase in glucose-driven ATP production for a given amount oftrimetazidine than does a compound that delivers trimetazidine alone.

The invention also provides compounds represented by formula (VII):

A-C  (VII),

in which A is a compound that shifts cardiac metabolism from fatty acidoxidation to glucose oxidation, and C is a NAD⁺ precursor molecule. Aand C may be covalently linked.

The compound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation may be PEGylated with an ethylene glycol moiety. Thecompound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation may have multiple ethylene glycol moieties, such asone, two three, four, five, or more ethylene glycol moieties. Theethylene glycol moiety may be represented by (CH₂CH₂O)_(x), in whichx=1-15. The ethylene glycol moiety may form a covalent linkage betweenthe compound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation and the NAD⁺ precursor molecule. The ethylene glycolmoiety may be separate from a covalent linkage between the compound thatshifts cardiac metabolism from fatty acid oxidation to glucose oxidationand the NAD⁺ precursor molecule.

The compound of formula (VII) may include nicotinic acid that iscovalently linked to a PEGylated form of trimetazidine. The nicotinicacid may be covalently linked via a PEGylated moiety, i.e., via anethylene glycol linkage. The nicotinic acid may be covalently linked viathe trimetazidine moiety.

The invention also provides compounds represented by formula (VIII):

A-L-C  (VIII),

in which A is a compound that shifts cardiac metabolism from fatty acidoxidation to glucose oxidation, L is a linker, and C is a NAD⁺ precursormolecule. A may be covalently linked to L, and L may be covalentlylinked to C.

The compound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation, the linker, and the NAD⁺ precursor molecule may be asdescribed above in relation to compounds of other formulas.

The invention also provides compositions that include at least two of(1) a compound that shifts cardiac metabolism from fatty acid oxidationto glucose oxidation, (2) a compound that promotes mitochondrialrespiration, and (3) a NAD⁺ precursor molecule. The aforementionedcomponents of the composition may be provided as separate molecules.

The compositions may include each of a (1) a compound that shiftscardiac metabolism from fatty acid oxidation to glucose oxidation, (2) acompound that promotes mitochondrial respiration, and (3) a NAD⁺precursor molecule. In such compositions, each of the three componentsmay be provided as a separate molecule. Alternatively, in suchcompositions, two of the components may be covalently linked as part ofsingle molecule, and the third component may be provided as a separatemolecule. For example, the compound that shifts cardiac metabolism fromfatty acid oxidation to glucose oxidation may be linked to the compoundthat promotes mitochondrial respiration, and the NAD⁺ precursor may beprovided as a separate molecule.

The compounds of the invention may be provided as co-crystals with othercompounds. Co-crystals are crystalline materials composed of two or moredifferent molecules in the same crystal lattice. The different moleculesmay be neutral and interact non-ionically within the lattice.Co-crystals of the invention may include one or more compounds of theinvention with one or more other molecules that stimulate mitochondrialrespiration or serve as NAD⁺ precursors. For example, a co-crystal mayinclude any of the following combinations: (1) a compound that shiftscardiac metabolism from fatty acid oxidation to glucose oxidation and(2) a NAD⁺ precursor molecule; (1) a compound that promotesmitochondrial respiration and (2) a NAD⁺ precursor molecule; (1) acompound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation and (2) a compound that promotes mitochondrialrespiration; (1) a molecule comprising a compound that shifts cardiacmetabolism from fatty acid oxidation to glucose oxidation covalentlylinked to a compound that promotes mitochondrial respiration and (2) aNAD⁺ precursor molecule. In specific embodiments, a co-crystal mayinclude (1) a compound of formula (I), (III), (IV), or (V) and (2)nicotinic acid, nicotinamide, or nicotinamide riboside.

The compounds may include one or more atoms that are enriched for anisotope. For example, the compounds may have one or more hydrogen atomsreplaced with deuterium or tritium. Isotopic substitution or enrichmentmay occur at carbon, sulfur, or phosphorus, or other atoms. Thecompounds may be isotopically substituted or enriched for a given atomat one or more positions within the compound, or the compounds may beisotopically substituted or enriched at all instances of a given atomwithin the compound.

The invention provides pharmaceutical compositions containing one ormore of the compounds described above. A pharmaceutical compositioncontaining the compounds may be in a form suitable for oral use, forexample, as tablets, troches, lozenges, fast-melts, aqueous or oilysuspensions, dispersible powders or granules, emulsions, hard or softcapsules, syrups or elixirs. Compositions intended for oral use may beprepared according to any method known in the art for the manufacture ofpharmaceutical compositions and such compositions may contain one ormore agents selected from sweetening agents, flavoring agents, coloringagents and preserving agents, in order to provide pharmaceuticallyelegant and palatable preparations. Tablets contain the compounds inadmixture with non-toxic pharmaceutically acceptable excipients whichare suitable for the manufacture of tablets. These excipients may be forexample, inert diluents, such as calcium carbonate, sodium carbonate,lactose, calcium phosphate or sodium phosphate; granulating anddisintegrating agents, for example corn starch, or alginic acid; bindingagents, for example starch, gelatin or acacia, and lubricating agents,for example magnesium stearate, stearic acid or talc. The tablets may beuncoated or they may be coated by known techniques to delaydisintegration in the stomach and absorption lower down in thegastrointestinal tract and thereby provide a sustained action over alonger period. For example, a time delay material such as glycerylmonostearate or glyceryl distearate may be employed. They may also becoated by the techniques described in U.S. Pat. Nos. 4,256,108,4,166,452 and 4,265,874, to form osmotic therapeutic tablets for controlrelease. Preparation and administration of compounds is discussed inU.S. Pat. No. 6,214,841 and U.S. Pub. 2003/0232877, incorporated byreference herein in their entirety.

Formulations for oral use may also be presented as hard gelatin capsulesin which the compounds are mixed with an inert solid diluent, forexample calcium carbonate, calcium phosphate or kaolin, or as softgelatin capsules in which the compounds are mixed with water or an oilmedium, for example peanut oil, liquid paraffin or olive oil.

An alternative oral formulation, where control of gastrointestinal tracthydrolysis of the compound is sought, can be achieved using acontrolled-release formulation, where a compound of the invention isencapsulated in an enteric coating.

Aqueous suspensions may contain the compounds in admixture withexcipients suitable for the manufacture of aqueous suspensions. Suchexcipients are suspending agents, for example sodiumcarboxymethylcellulose, methylcellulose, hydroxypropylmethylcellulose,sodium alginate, polyvinylpyrrolidone, gum tragacanth and gum acacia;dispersing or wetting agents such as a naturally occurring phosphatide,for example lecithin, or condensation products of an alkylene oxide withfatty acids, for example, polyoxyethylene stearate, or condensationproducts of ethylene oxide with long chain aliphatic alcohols, forexample heptadecaethyleneoxycetanol, or condensation products ofethylene oxide with partial esters derived from fatty acids and ahexitol such a polyoxyethylene with partial esters derived from fattyacids and hexitol anhydrides, for example polyoxyethylene sorbitanmonooleate. The aqueous suspensions may also contain one or morepreservatives, for example ethyl, or n-propyl p-hydroxybenzoate, one ormore coloring agents, one or more flavoring agents, and one or moresweetening agents, such as sucrose or saccharin.

Oily suspensions may be formulated by suspending the compounds in avegetable oil, for example, arachis oil, olive oil, sesame oil orcoconut oil, or in a mineral oil such as liquid paraffin. The oilysuspensions may contain a thickening agent, for example beeswax, hardparaffin or cetyl alcohol. Sweetening agents such as those set forthabove, and flavoring agents may be added to provide a palatable oralpreparation. These compositions may be preserved by the addition of ananti-oxidant such as ascorbic acid.

Dispersible powders and granules suitable for preparation of an aqueoussuspension by the addition of water provide the compounds in admixturewith a dispersing or wetting agent, suspending agent and one or morepreservatives. Suitable dispersing or wetting agents and suspendingagents are exemplified, for example sweetening, flavoring and coloringagents, may also be present.

The pharmaceutical compositions of the invention may also be in the formof oil-in-water emulsions. The oily phase may be a vegetable oil, forexample olive oil or arachis oil, or a mineral oil, for example liquidparaffin or mixtures of these. Suitable emulsifying agents may benaturally-occurring gums, for example gum acacia or gum tragacanth,naturally occurring phosphatides, for example soya bean, lecithin, andesters or partial esters derived from fatty acids and hexitolanhydrides, for example sorbitan monooleate and condensation products ofthe said partial esters with ethylene oxide, for example polyoxyethylenesorbitan monooleate. The emulsions may also contain sweetening andflavoring agents.

Syrups and elixirs may be formulated with sweetening agents, such asglycerol, propylene glycol, sorbitol or sucrose. Such formulations mayalso contain a demulcent, a preservative, and agents for flavoringand/or coloring. The pharmaceutical compositions may be in the form of asterile injectable aqueous or oleaginous suspension. This suspension maybe formulated according to the known art using those suitable dispersingor wetting agents and suspending agents which have been mentioned above.The sterile injectable preparation may also be in a sterile injectablesolution or suspension in a non-toxic parenterally acceptable diluent orsolvent, for example as a solution in 1,3-butanediol. Among theacceptable vehicles and solvents that may be employed are water,Ringer's solution and isotonic sodium chloride solution. In addition,sterile, fixed oils are conventionally employed as a solvent orsuspending medium. For this purpose any bland fixed oil may be employedincluding synthetic mono- or di-glycerides. In addition, fatty acidssuch as oleic acid find use in the preparation of injectables.

The compounds of the invention are useful for improving cardiacefficiency. A variety of definitions of cardiac efficiency exist in themedical literature. See, e.g. Schipke, J. D. Cardiac efficiency, BasicRes. Cardiol. 89:207-40 (1994); and Gibbs, C. L. and Barclay, C. J.Cardiac efficiency, Cardiovasc. Res. 30:627-634 (1995), incorporatedherein by reference. One definition of cardiac mechanical efficiency isthe ratio of external cardiac power to cardiac energy expenditure by theleft ventricle. See Lopaschuk G. D., et al., Myocardial Fatty AcidMetabolism in Health and Disease, Phys. Rev. 90:207-258 (2010),incorporated herein by reference. Another definition is the ratiobetween stroke work and oxygen consumption, which ranges from 20-25% inthe normal human heart. Visser, F., Measuring cardiac efficiency: is ituseful? Hear Metab. 39:3-4 (2008), incorporated herein by reference.Another definition is the ratio of the stroke volume to mean arterialblood pressure. Any suitable definition of cardiac efficiency may beused to measure the effects of compounds of the invention

The invention also provides methods of altering cardiac metabolism in asubject to increase glucose oxidation relative to fatty acid oxidation.The methods may include providing a composition of the invention, suchas any the compounds described above, including the compoundsrepresented by formulas (I), (II), (III), (IV), or (V) or formulationsthereof.

The methods may include providing a compound that shifts cardiacmetabolism from fatty acid oxidation to glucose oxidation, as describedabove, and a compound that promotes mitochondrial respiration, asdescribed above. The compounds may be provided as components of a singlemolecule, as separate molecules in a single composition, or as separatecompositions.

The methods may also include providing a NAD⁺ precursor molecule, asdescribed above. In methods that involve providing a compound thatshifts cardiac metabolism from fatty acid oxidation to glucoseoxidation, a compound that promotes mitochondrial respiration, and aNAD⁺ precursor molecule, compounds may be provided as components of asingle molecule, two different molecules, or three different molecules.The compounds may be provided in one, two, three, or any number ofdifferent compositions. The compounds may be provided together,separately, or in any combination. The compounds may be providedsimultaneously or sequentially. The compounds may be provided atdifferent intervals, with different frequency, in different quantities,or at different dosages.

The invention also provides methods of treating conditions by providingcompositions of the invention. The condition may be heart disease, suchas heart failure, ischemic heart disease, diabetic cardiomyopathy,rheumatic heart disease, valvular heart disease, aneurysm,atherosclerosis, high blood pressure (hypertension), peripheral arterialdisease, angina, atherosclerosis, coronary artery disease, coronaryheart disease, heart attack, atherosclerosis, cerebral vascular disease,stroke, transient ischemic attacks, atherosclerosis, cardiomyopathy,pericardial disease, valvular heart disease, or congenital heartdisease.

Examples

Protocol

The effects of compounds of the invention on mitochondrial function wereanalyzed. HepG2 cells were dosed with test compound and in real time theextracellular oxygen levels and pH were measured using the XFe96 fluxanalyzer (Seahorse Biosciences). XFe Technology uses solid-state sensorsto simultaneously measure both oxygen consumption rate (OCR) andextracellular acidification rate (ECAR) to determine effects onoxidative phosphorylation (OXPHOS) and glycolysis simultaneously. Thecells were then subjected to sequential exposure to various inhibitorsof mitochondrial function to assess cellular metabolism.

Data Interpretation.

A compound was identified as positive mitochondrial-active compound whenit caused a change in oxygen consumption rate (OCR) or extracellularacidification rate (ECAR) in the absence of cytotoxicity. Cytotoxicitywas determined when both OXPHOS (OCR) and glycolysis (ECAR) wereinhibited.

Definition of Mitochondrial Parameters.

Oxygen consumption rate (OCR) is a measurement of oxygen content inextracellular media. Changes in OCR indicate effects on mitochondrialfunction and can be bi-directional. A decrease is due to an inhibitionof mitochondrial respiration, while an increase may indicate anuncoupler, in which respiration is not linked to energy production.

${OCR} = \frac{{{compound}\mspace{14mu} {OCR}} - {{non}\mspace{14mu} {mitochodiral}\mspace{14mu} {OCR}}}{{{basal}\mspace{14mu} {OCR}} - {{non}\mspace{14mu} {mitochondrial}\mspace{14mu} {OCR}}}$

Extracellular acidification rate (ECAR) is the measurement ofextracellular proton concentration (pH). An increase in signal means anincrease in rate in number of pH ions (thus decreasing pH value) andseen as an increase in glycolysis. ECAR is expressed as a fraction ofbasal control (rate prior to addition of compound).

${ECAR} = \frac{{compound}\mspace{14mu} {ECAR}}{{basal}\mspace{14mu} {ECAR}}$

Reserve capacity is the measured ability of cells to respond to anincrease in energy demand. A reduction indicates mitochondrialdysfunction. This measurement demonstrates how close to the bioenergeticlimit the cell is.

${{reserve}\mspace{14mu} {capacity}} = \frac{{{FCCP}\mspace{14mu} {OCR}} - {{non}\mspace{14mu} {mitochodrial}\mspace{14mu} {OCR}}}{{{basal}\mspace{14mu} {OCR}} - {{non}\mspace{14mu} {mitochondrial}\mspace{14mu} {OCR}}}$

Mitochondrial Stress Test.

A series of compounds were added sequentially to the cells to assess abioenergetics profile, effects of test compounds on parameters such asproton leak, and reserve capacity. This can be used to assist inunderstanding potential mechanisms of mitochondrial toxicity. Thefollowing compounds were added in order: (1) oligomycin, (2) FCCP, and(3) rotenone and antimycin A.

Oligomycin is a known inhibitor of ATP synthase and prevents theformation of ATP. Oligomycin treatment provides a measurement of theamount of oxygen consumption related to ATP production and ATP turnover.The addition of oligomycin results in a decrease in OCR under normalconditions, and residual OCR is related to the natural proton leak.

FCCP is a protonophore and is a known uncoupler of oxygen consumptionfrom ATP production. FCCP treatment allows the maximum achievabletransfer of electrons and oxygen consumption rate and provides ameasurement of reserve capacity.

Rotenone and antimycin A are known inhibitors of complex I and III ofthe electron transport chain, respectively. Treatment with thesecompounds inhibits electron transport completely, and any residualoxygen consumption is due to non-mitochondrial activity via oxygenrequiring enzymes.

Definition of Mechanisms.

An electron transport chain inhibitor is an inhibitor of mitochondrialrespiration that causes an increase in glycolysis as an adaptiveresponse (e.g. decrease OCR and increase in ECAR).

The inhibition of oxygen consumption may also be due to reducedsubstrate availability (e.g. glucose, fatty acids, glutamine, pyruvate),for example, via transporter inhibition. Compounds that reduce theavailability of substrates are substrate inhibitors. A substrateinhibitor does not result in an increase in glycolysis (e.g. OCRdecrease, no response in ECAR).

Compounds that inhibit the coupling of the oxidation process from ATPproduction are known as uncouplers. These result in an increase inmitochondrial respiration (OCR) but inhibition of ATP production.

FIG. 1 is a table summarizing the effects of various compounds onmitochondrial function.

FIG. 2 is a table summarizing the effects of nicotinamide on variousmitochondrial functional parameters.

FIG. 3 is a series of graphs showing the effects of nicotinamide onoxygen consumption rate and reserve capacity.

FIG. 4 is a series of graphs showing the effects of nicotinamide onextracellular acidification rate.

FIG. 5 is a table summarizing the effects of a combination oftrimetazidine and nicotinamide on various mitochondrial functionalparameters.

FIG. 6 is a series of graphs showing the effects of a combination oftrimetazidine and nicotinamide on oxygen consumption rate and reservecapacity.

FIG. 7 is a series of graphs showing the effects of a combination oftrimetazidine and nicotinamide on extracellular acidification rate.

FIG. 8 is a table summarizing the effects of succinate on variousmitochondrial functional parameters.

FIG. 9 is a series of graphs showing the effects of succinate on oxygenconsumption rate and reserve capacity.

FIG. 10 is a series of graphs showing the effects of succinate onextracellular acidification rate.

FIG. 11 is a table summarizing the effects of compound CV-8816 onvarious mitochondrial functional parameters.

FIG. 12 is a series of graphs showing the effects of compound CV-8816 onoxygen consumption rate and reserve capacity.

FIG. 13 is a series of graphs showing the effects of compound CV-8816 onextracellular acidification rate.

FIG. 14 is a table summarizing the effects of compound CV-8814 onvarious mitochondrial functional parameters.

FIG. 15 is a series of graphs showing the effects of compound CV-8814 onoxygen consumption rate and reserve capacity.

FIG. 16 is a series of graphs showing the effects of compound CV-8814 onextracellular acidification rate.

FIG. 17 is a table summarizing the effects of trimetazidine on variousmitochondrial functional parameters.

FIG. 18 is a series of graphs showing the effects of trimetazidine onoxygen consumption rate and reserve capacity.

FIG. 19 is a series of graphs showing the effects of trimetazidine onextracellular acidification rate.

FIG. 20 is a table summarizing the effects of compound CV-8815 onvarious mitochondrial functional parameters.

FIG. 21 is a series of graphs showing the effects of compound CV-8815 onoxygen consumption rate and reserve capacity.

FIG. 22 is a series of graphs showing the effects of compound CV-8815 onextracellular acidification rate.

FIG. 23 is a table summarizing the effects of a combination ofsuccinate, nicotinamide, and trimetazidine on various mitochondrialfunctional parameters.

FIG. 24 is a series of graphs showing the effects of a combination ofsuccinate, nicotinamide, and trimetazidine on oxygen consumption rateand reserve capacity.

FIG. 25 is a series of graphs showing the effects of a combination ofsuccinate, nicotinamide, and trimetazidine on extracellularacidification rate.

FIG. 26 is a table summarizing the effects of a combination oftrimetazidine analog 2 and nicotinamide on various mitochondrialfunctional parameters.

FIG. 27 is a series of graphs showing the effects of a combination oftrimetazidine analog 2 and nicotinamide on oxygen consumption rate andreserve capacity.

FIG. 28 is a series of graphs showing the effects a combination oftrimetazidine analog 2 and nicotinamide on extracellular acidificationrate.

FIG. 29 is a table summarizing the effects of a combination oftrimetazidine analog 1 and nicotinamide on various mitochondrialfunctional parameters.

FIG. 30 is a series of graphs showing the effects of a combination oftrimetazidine analog 1 and nicotinamide on oxygen consumption rate andreserve capacity.

FIG. 31 is a series of graphs showing the effects of a combination oftrimetazidine analog 1 and nicotinamide on extracellular acidificationrate.

FIG. 32 is a table summarizing the effects of a combination oftrimetazidine analog 3 and nicotinamide on various mitochondrialfunctional parameters.

FIG. 33 is a series of graphs showing the effects of a combination oftrimetazidine analog 3 and nicotinamide on oxygen consumption rate andreserve capacity.

FIG. 34 is a series of graphs showing the effects of a combination oftrimetazidine analog 3 and nicotinamide on extracellular acidificationrate.

FIG. 35 is a table summarizing the effects of a combination of succinateand nicotinamide on various mitochondrial functional parameters.

FIG. 36 is a series of graphs showing the effects of a combination ofsuccinate and nicotinamide on oxygen consumption rate and reservecapacity.

FIG. 37 is a series of graphs showing the effects of a combination ofsuccinate and nicotinamide on extracellular acidification rate.

Effect of compositions on coronary flow, cardiac function, and infarctsize. The effect of compositions on the coronary flow, cardiac function,and infarct size was analyzed.

FIG. 38 is a schematic of the ischemia-reperfusion (IR) method used toanalyze the effects of compositions of the invention on coronary flow,cardiac function, and infarct size. At time 0, mice were given (1) 20 μMtrimetazidine (TMZ), (2) 2 μM each of trimetazidine, nicotinamide, andsuccinate (TNF), (3) 20 μM each of trimetazidine, nicotinamide, andsuccinate (TNS), or (4) the delivery vehicle (CON). At 20 minutes,ischemia was induced, and coronary flow was analyzed. At 50 minutes,reperfusion was initiated to restore blood flow. At 170 minutes,coronary flow and cardiac function was analyzed, and then the heartswere preserved, sectioned, and infarct size was measured bytriphenyltetrazolium chloride (TTC) staining.

FIG. 39 is a graph of coronary flow of after IR. Data is expressed asratio cardiac flow at 170 minutes to cardiac flow at 20 minutes. TNStreatment preserved coronary flow after IR. Raw data is provided inTables 1-2.

TABLE 1 CF170/CF20 CF20 (ml/min) CF170 (ml/min) (ul/ml) CON11 2.31E+001.11E−01 4.81E+01 CON13 1.07E+00 4.80E−02 4.48E+01 CON14 8.28E−014.50E−02 5.43E+01 CON9 2.11E+00 6.96E−02 3.30E+01 CON10 1.85E+004.92E−02 2.66E+01 CON7 1.57E+00 5.40E−02 3.44E+01 CON8 3.22E+00 6.78E−022.11E+01 CON5 2.18E+00 6.60E−02 3.03E+01 CON3 2.24E+00 7.92E−02 3.53E+01CON4 2.22E+00 7.84E−02 3.53E+01 CON2 1.68E+00 5.12E−02 3.05E+01 MEAN1.93E+00 6.54E−02 3.58E+01 SD 6.50E−01 1.94E−02 9.72E+00 SE 1.96E−015.86E−03 2.93E+00 TTEST TMZ4 2.13E+00 5.16E−02 2.42E+01 TMZ3 1.70E+001.00E−01 5.87E+01 TMZ1 2.18E+00 7.78E−02 3.57E+01 TMZ2 3.83E+00 1.29E−013.37E+01 TMZ7 1.72E+00 8.98E−02 5.21E+01 TMZ8 2.40E+00 6.56E−02 2.73E+01TMZ5 2.14E+00 5.56E−02 2.60E+01 TMZ9 2.03E+00 1.30E−01 6.39E+01 MEAN2.27E+00 8.74E−02 4.02E+01 SD 6.75E−01 3.06E−02 1.57E+01 SE 2.39E−011.08E−02 5.56E+00 TTEST TNF1 2.24E+00 4.80E−02 2.14E+01 TNF2 2.24E+003.80E−02 1.69E+01 TNF3 7.32E−01 4.80E−02 6.56E+01 TNF4 8.20E−01 4.90E−025.98E+01 TNF5 1.09E+00 2.70E−02 2.48E+01 TNF6 9.48E−01 1.50E−01 1.58E+02TNF7 8.08E−01 3.70E−02 4.58E+01 TNF8 1.20E+00 4.60E−02 3.83E+01 TNF91.45E+00 1.21E−01 8.33E+01 TNF10 1.20E+00 1.52E−02 1.27E+01 MEAN1.27E+00 5.79E−02 5.27E+01 SD 5.56E−01 4.28E−02 4.37E+01 SE 1.76E−011.35E−02 1.38E+01 TTEST 2.21E−02 6.06E−01 2.26E−01 TNS1 1.52E+004.70E−02 3.08E+01 TNS2 9.30E−01 2.90E−02 3.12E+01 TNS3 2.24E+00 1.67E−017.46E+01 TNS5 5.64E−01 5.00E−02 8.87E+01 TNS6 6.28E−01 4.40E−02 7.01E+01TNS7 1.08E+00 6.40E−02 5.95E+01 TNS8 8.72E−01 2.30E−02 2.64E+01 TNS91.18E+00 8.50E−02 7.23E+01 TNS10 1.70E+00 1.84E−01 1.08E+02 MEAN1.19E+00 7.70E−02 6.24E+01 SD 5.43E−01 5.89E−02 2.82E+01 SE 1.81E−011.96E−02 9.42E+00 TTEST 1.35E−02 5.45E−01 8.80E−03 vs TMZ 6.82E−02

TABLE 2 CON TMZ TNF TNS MEAN 36 40 53 62 SD 10 16 44 28 SE 3 6 14 9

FIG. 40 is graph of left ventricular developed pressure (LVDP) after IR.Blue bars indicate LVDP at 20 minutes, and orange bars indicate LVDP at170 minutes. TMZ, TNS, and TNF treatment prevented a decline in cardiacfunction after IR. Raw data is provided in Tables 3-6.

TABLE 3 pre-ischemia LVESP LVEDP HR LVDP LVDP × HR 5-18-CN CON116.61E+01 6.20E+00 3.28E+02 5.99E+01 1.97E+04 CON12 8.15E+01 3.73E+003.56E+02 7.78E+01 2.77E+04 6-10-CN CON13 8.00E+01 −3.74E+00 1.37E+028.37E+01 1.15E+04 CON14 7.28E+01 6.12E+00 4.54E+02 6.67E+01 3.03E+045-15-CN CON9 8.07E+01 5.00E+00 1.42E+02 7.57E+01 1.08E+04 CON10 4.91E+011.15E+00 3.21E+02 4.80E+01 1.54E+04 5-12-CN CON7 8.55E+01 6.35E+003.05E+02 7.91E+01 2.42E+04 CON8 5.06E+01 1.68E+00 3.04E+02 4.90E+011.49E+04 5-9-CN CONS 5.45E+01 5.63E+00 2.75E+02 4.89E+01 1.35E+04 CON66.37E+01 4.31E+00 3.08E+02 5.94E+01 1.83E+04 5-7-CN CON3 7.32E+012.70E+00 2.40E+02 7.05E+01 1.69E+04 CON4 4.91E+01 1.65E−01 3.14E+024.89E+01 1.54E+04 5-5-CN CON1 9.48E+01 7.96E+00 3.04E+02 8.68E+012.64E+04 CON2 4.69E+01 1.64E−01 4.02E+02 4.67E+01 1.88E+04 MEAN 6.77E+013.39E+00 2.99E+02 6.44E+01 1.88E+04 SD 1.58E+01 3.21E+00 8.52E+011.46E+01 6.12E+03 SE 4.21E+00 8.57E−01 2.28E+01 3.91E+00 1.63E+03 TTEST2.42E−04 5-14-TMZ TMZ3 7.58E+01 6.53E+00 2.63E+02 6.93E+01 1.83E+04 TMZ48.44E+01 5.43E+00 2.93E+02 7.90E+01 2.31E+04 5-11-TMZ TMZ1 7.15E+016.76E+00 1.66E+02 6.48E+01 1.08E+04 TMZ2 5.47E+01 1.74E+00 3.35E+025.30E+01 1.77E+04 5-8-TMZ TMZ7 6.87E+01 3.58E+00 3.58E+02 6.51E+012.33E+04 TMZ8 4.27E+01 4.71E+00 3.33E+02 3.80E+01 1.26E+04 5-6-TMZ TMZ53.30E+01 4.77E+00 3.48E+02 2.82E+01 9.82E+03 TMZ6 3.30E+01 1.46E+003.21E+02 3.15E+01 1.01E+04 5-4-TMZ TMZ9 6.60E+01 7.25E+00 2.67E+025.87E+01 1.57E+04 TMZ10 7.38E+01 2.70E+00 3.32E+02 7.11E+01 2.36E+04MEAN 6.03E+01 4.49E+00 3.02E+02 5.59E+01 1.68E+04 SD 1.85E+01 2.07E+005.75E+01 1.77E+01 5.56E+03 SE 5.84E+00 6.56E−01 1.82E+01 5.58E+001.76E+03 3.85E−01 5-19-TNF TNF1 5.02E+01 3.04E+00 4.09E+02 4.72E+011.93E+04 TNF2 4.65E+01 1.76E−01 2.76E+02 4.63E+01 1.28E+04 6-8-TNF TNF37.13E+01 1.53E+00 6.48E+01 6.97E+01 4.52E+03 TNF4 9.97E+01 4.15E+001.54E+02 9.55E+01 1.47E+04 6-12-TNF TNF5 7.14E+01 −3.42E+00 2.77E+027.49E+01 2.07E+04 TNF6 8.98E+01 8.85E+00 3.10E+02 8.09E+01 2.51E+046-14-TNF TNF7 6.58E+01 7.01E+00 3.98E+02 5.88E+01 2.34E+04 TNF8 5.99E+011.02E+00 2.28E+02 5.89E+01 1.34E+04 6-15-TNF TNF9 7.89E+01 2.37E−012.71E+02 7.87E+01 2.13E+04 TNF10 4.01E+01 1.88E+00 3.14E+02 3.82E+011.20E+04 MEAN 6.74E+01 2.45E+00 2.70E+02 6.49E+01 1.67E+04 SD 1.90E+013.54E+00 1.04E+02 1.81E+01 6.32E+03 SE 6.00E+00 1.12E+00 3.28E+015.73E+00 2.00E+03 1.38E−01 5-20-TNS TNS1 5.59E+01 5.23E+00 3.33E+025.07E+01 1.69E+04 TNS2 5.54E+01 −1.83E+00 1.24E+02 5.72E+01 7.09E+036-7-TNS TNS3 8.78E+01 1.53E+00 1.64E+02 8.63E+01 1.42E+04 TNS4 1.07E+029.86E+00 2.41E+02 9.74E+01 2.35E+04 6-9-TNS TNS5 8.97E+01 2.34E+008.35E+01 8.74E+01 7.29E+03 TNS6 6.17E+01 6.21E+00 1.85E+02 5.55E+011.03E+04 6-13-TNS TNS7 6.62E+01 4.14E+00 3.36E+02 6.21E+01 2.09E+04 TNS86.54E+01 1.22E+01 1.22E+02 5.32E+01 6.47E+03 6-15-TNS TNS9 6.16E+013.64E+00 3.45E+02 5.80E+01 2.00E+04 TNS10 5.44E+01 2.47E+00 4.12E+025.20E+01 2.14E+04 MEAN 7.05E+01 4.58E+00 2.35E+02 6.60E+01 1.48E+04 SD1.80E+01 4.09E+00 1.15E+02 1.74E+01 6.61E+03 SE 5.69E+00 1.29E+003.63E+01 5.49E+00 2.09E+03 7.89E−02

TABLE 4 after 2 h LVDP × reperfusion LVESP LVEDP HR LVDP HR 5-18-CNCON11 7.78E+01 3.68E+01 1.18E+02 4.10E+01 4.82E+03 CON12 7.07E+012.23E+01 9.23E+01 4.84E+01 4.47E+03 6-10-CN CON13 6.48E+01 5.54E+015.72E+02 9.39E+00 5.38E+03 CON14 9.54E+01 5.64E+01 2.08E+02 3.90E+018.12E+03 5-15-CN CON9 5.18E+01 2.71E+01 1.75E+02 2.47E+01 4.33E+03 CON101.10E+02 3.13E+01 5.76E+01 7.84E+01 4.51E+03 5-12-CN CON7 3.93E+011.42E+01 9.11E+01 2.51E+01 2.29E+03 CON8 5.29E+01 9.48E+00 6.07E+014.34E+01 2.64E+03 5-9-CN CONS 6.56E+01 4.89E+01 6.50E+01 1.67E+011.09E+03 CON6 7.44E+01 6.56E+01 3.78E+01 8.81E+00 3.33E+02 5-7-CN CON36.35E+01 9.99E+00 1.15E+02 5.35E+01 6.18E+03 CON4 8.76E+01 5.34E+011.06E+02 3.43E+01 3.65E+03 5-5-CN CON1 9.29E+01 4.38E+01 2.61E+024.91E+01 1.28E+04 CON2 5.18E+01 4.43E+00 2.57E+02 4.74E+01 1.22E+04 MEAN7.13E+01 3.42E+01 1.58E+02 3.71E+01 5.20E+03 SD 1.98E+01 2.02E+011.39E+02 1.90E+01 3.68E+03 SE 5.29E+00 5.40E+00 3.72E+01 5.08E+009.83E+02 TTEST 5-14-TMZ TMZ3 5.07E+01 2.93E+01 1.18E+02 2.14E+012.52E+03 TMZ4 7.66E+01 3.31E+01 1.19E+02 4.34E+01 5.15E+03 5-11-TMZ TMZ19.19E+01 3.96E+01 1.01E+02 5.22E+01 5.28E+03 TMZ2 4.77E+01 1.80E+011.51E+02 2.97E+01 4.49E+03 5-8-TMZ TMZ7 5.18E+01 3.36E+00 6.70E+014.84E+01 3.24E+03 TMZ8 4.86E+01 1.87E+00 9.22E+01 4.67E+01 4.31E+035-6-TMZ TMZ5 6.09E+01 1.99E+01 2.22E+02 4.10E+01 9.11E+03 TMZ6 1.09E+023.21E+01 1.70E+02 7.65E+01 1.30E+04 5-4-TMZ TMZ9 7.38E+01 1.84E+011.16E+02 5.53E+01 6.44E+03 TMZ10 7.61E+01 1.77E+00 2.38E+02 7.43E+011.77E+04 MEAN 6.86E+01 1.97E+01 1.39E+02 4.89E+01 6.82E+03 SD 2.05E+011.39E+01 5.58E+01 1.73E+01 4.82E+03 SE 6.49E+00 4.39E+00 1.77E+015.46E+00 1.52E+03 5-19-TNF TNF1 8.37E+01 6.66E+01 1.53E+02 1.71E+012.62E+03 TNF2 6.19E+00 5.54E+00 2.13E+03 6.48E−01 1.38E+03 6-8-TNF TNF38.99E+01 1.88E+01 1.05E+01 7.11E+01 7.49E+02 TNF4 6.06E+01 1.34E+018.10E+01 4.72E+01 3.82E+03 6-12-TNF TNF5 1.54E+02 4.15E+01 2.20E+011.13E+02 2.48E+03 TNF6 1.30E+02 4.25E+01 3.33E+01 8.77E+01 2.92E+036-14-TNF TNF7 5.70E+01 4.00E+01 4.00E+01 1.70E+01 6.80E+02 TNF8 3.76E+011.87E+01 5.36E+01 1.88E+01 1.01E+03 6-15-TNF TNF9 6.23E+01 3.38E+011.97E+02 2.85E+01 5.59E+03 TNF10 7.85E+01 2.75E+01 7.85E+01 5.10E+014.00E+03 MEAN 7.60E+01 3.09E+01 2.80E+02 4.52E+01 2.53E+03 SD 4.28E+011.79E+01 6.54E+02 3.59E+01 1.62E+03 SE 1.35E+01 5.65E+00 2.07E+021.14E+01 5.12E+02 5-20-TNS TNS 1 6.47E+01 1.78E+01 1.04E+02 4.69E+014.88E+03 TNS2 8.95E+01 3.03E+01 5.55E+01 5.92E+01 3.29E+03 6-7-TNS TNS37.79E+01 6.34E+01 1.28E+02 1.45E+01 1.85E+03 TNS4 7.74E+01 2.73E+011.02E+02 5.01E+01 5.09E+03 6-9-TNS TNS5 1.37E+02 5.63E+01 1.63E+018.08E+01 1.32E+03 TNS6 8.59E+01 1.23E+01 1.06E+02 7.36E+01 7.79E+036-13-TNS TNS7 5.76E+01 5.16E+01 1.35E+02 6.00E+00 8.07E+02 TNS8 4.96E+011.53E+01 1.22E+02 3.43E+01 4.20E+03 6-15-TNS TNS 9 9.97E+01 3.00E+017.46E+01 6.98E+01 5.21E+03 TNS10 4.32E+01 −4.32E+00 7.20E+01 4.75E+013.42E+03 MEAN 7.83E+01 3.00E+01 9.15E+01 4.83E+01 3.79E+03 SD 2.74E+012.14E+01 3.69E+01 2.45E+01 2.11E+03 SE 8.67E+00 6.78E+00 1.17E+017.75E+00 6.69E+02

TABLE 5 pre- after 2 h ischemia +dp/dtm −dp/dtm reperfusion +dp/dtm−dp/dtm 5-18-CN CON11 2.60E+03 −1.82E+03 CON11 1.44E+03 −8.67E+02 CON122.95E+03 −2.58E+03 CON12 1.63E+03 −1.07E+03 6-10-CN CON13 3.10E+03−2.42E+03 CON13 2.25E+02 −2.22E+02 CON14 3.08E+03 −2.10E+03 CON143.44E+02 −2.87E+02 5-15-CN CON9 2.28E+03 −1.38E+03 CON9 9.45E+02−5.54E+02 CON10 2.06E+03 −1.50E+03 CON10 2.29E+03 −1.75E+03 5-12-CN CON72.71E+03 −2.10E+03 CON7 2.51E+02 −2.55E+02 CON8 1.58E+03 −1.10E+03 CON83.63E+02 −3.05E+02 5-9-CN CONS 2.17E+03 −1.50E+03 CONS 2.39E+02−2.41E+02 CON6 2.25E+03 −1.62E+03 CON6 1.47E+02 −1.49E+02 5-7-CN CON32.63E+03 −2.06E+03 CON3 1.63E+03 −1.06E+03 CON4 2.05E+03 −1.38E+03 CON41.10E+03 −7.03E+02 5-5-CN CON1 3.17E+03 −2.37E+03 CON1 1.03E+03−1.12E+03 CON2 2.10E+03 −1.50E+03 CON2 1.75E+03 −1.27E+03 MEAN 2.48E+03−1.82E+03 MEAN 9.56E+02 −7.04E+02 SD 4.84E+02 4.56E+02 SD 7.08E+024.95E+02 SE 1.29E+02 1.22E+02 SE 1.89E+02 1.32E+02 TTEST TTEST 5-14-TMZTMZ3 2.41E+03 −1.69E+03 TMZ3 4.14E+02 −3.57E+02 TMZ4 2.77E+03 −2.26E+03TMZ4 1.48E+03 −1.15E+03 5-11-TMZ TMZ1 1.80E+03 −1.59E+03 TMZ1 1.38E+03−7.45E+02 TMZ2 2.15E+03 −1.80E+03 TMZ2 1.06E+03 −6.85E+02 5-8-TMZ TMZ73.40E+03 −2.59E+03 TMZ7 3.44E+02 −3.39E+02 TMZ8 1.75E+03 −1.20E+03 TMZ87.36E+02 −4.28E+02 5-6-TMZ TMZ5 1.27E+03 −8.82E+02 TMZ5 1.28E+03−8.38E+02 TMZ6 1.24E+03 −6.59E+02 TMZ6 1.85E+03 −1.06E+03 5-4-TMZ TMZ91.98E+03 −1.41E+03 TMZ9 1.13E+03 −6.38E+02 TMZ10 2.02E+03 −1.56E+03TMZ10 1.62E+03 −9.83E+02 MEAN 2.08E+03 −1.56E+03 MEAN 1.13E+03 −7.22E+02SD 6.58E+02 5.81E+02 SD 5.01E+02 2.90E+02 SE 2.08E+02 1.84E+02 SE1.58E+02 9.16E+01 5.16E−01 9.18E−01 5-19-TNF TNF1 2.67E+03 −1.49E+03TNF1 3.86E+02 −3.75E+02 TNF2 2.85E+03 −1.44E+03 TNF2 1.46E+02 −1.43E+026-8-TNF TNF3 1.53E+03 −7.24E+02 TNF3 2.28E+02 −2.34E+02 TNF4 3.86E+03−2.59E+03 TNF4 2.84E+02 −2.40E+02 6-12-TNF TNF5 3.29E+03 −2.34E+03 TNF52.92E+03 −2.08E+03 TNF6 3.03E+03 −1.90E+03 TNF6 2.48E+03 −1.84E+036-14-TNF TNF7 3.22E+03 −1.62E+03 TNF7 2.53E+02 −2.48E+02 TNF8 1.74E+03−1.12E+03 TNF8 1.53E+02 −1.52E+02 6-15-TNF TNF9 2.14E+03 −2.33E+03 TNF91.04E+03 −6.31E+02 TNF10 1.86E+03 −9.97E+02 TNF10 2.04E+03 −1.34E+03MEAN 2.62E+03 −1.65E+03 MEAN 9.93E+02 −7.29E+02 SD 7.71E+02 6.26E+02 SD1.08E+03 7.43E+02 SE 2.44E+02 1.98E+02 SE 3.41E+02 2.35E+02 1.09E−037.48E−03 5-20-TNS TNS1 2.37E+03 −1.60E+03 TNS1 1.79E+03 −1.12E+03 TNS22.87E+03 −2.53E+03 TNS2 1.84E+03 −1.30E+03 6-7-TNS TNS3 4.00E+03−2.67E+03 TNS3 2.91E+02 −3.02E+02 TNS4 3.32E+03 −2.63E+03 TNS4 1.62E+03−1.30E+03 6-9-TNS TNS5 3.36E+03 −2.21E+03 TNS5 2.43E+02 −2.46E+02 TNS62.53E+03 −1.89E+03 TNS6 2.36E+03 −1.74E+03 6-13-TNS TNS7 2.92E+03−1.75E+03 TNS7 2.49E+02 −2.47E+02 TNS8 1.12E+03 −7.42E+02 TNS8 1.29E+03−8.50E+02 6-15-TNS TNS9 2.29E+03 −1.75E+03 TNS9 2.06E+03 −1.59E+03 TNS102.11E+03 −1.58E+03 TNS10 1.26E+03 −1.10E+03 MEAN 2.69E+03 −1.94E+03 MEAN1.30E+03 −9.80E+02 SD 7.99E+02 5.95E+02 SD 7.86E+02 5.52E+02 SE 2.53E+021.88E+02 SE 2.49E+02 1.75E+02 9.96E−04 1.55E−03

TABLE 6 CON TMZ TNF TNS T20 Mean 64.36 55.86 64.90 65.96 T20 SE 3.915.58 5.73 5.49 T170 Mean 37.09 48.91 45.16 48.27 T170 SE 5.08 5.46 11.367.75

FIG. 41 shows images of TTC-stained heart slices after IR. TMZ and TNStreatment decreased infarct size after IR.

FIG. 42 is graph of infarct size after IR. TMZ and TNS treatmentdecreased infarct size after IR. Raw data is provided in Tables 7-55.

TABLE 7 CN11 raw values 1 Slide11.jpg 1649 2 Slide11.jpg 10 0.06 3Slide11.jpg 1385 8.40 4 Slide11.jpg 2808 5 Slide11.jpg 104 0.81 6Slide11.jpg 2525 19.78 7 Slide11.jpg 3807 8 Slide11.jpg 1014 7.99 9Slide11.jpg 2207 17.39 10 Slide11.jpg 3952 11 Slide11.jpg 15 0.08 12Slide11.jpg 3300 17.54 13 Slide11.jpg 3376 14 Slide11.jpg 103 0.92 15Slide11.jpg 2816 25.02 16 Slide11.jpg 1616 17 Slide11.jpg 975 6.03 18Slide11.jpg 409 2.53 19 Slide11.jpg 2805 20 Slide11.jpg 819 6.42 21Slide11.jpg 1496 11.73 22 Slide11.jpg 3973 23 Slide11.jpg 1047 7.91 24Slide11.jpg 2465 18.61 25 Slide11.jpg 3971 26 Slide11.jpg 1102 5.83 27Slide11.jpg 2430 12.85 28 Slide11.jpg 3516 29 Slide11.jpg 1919 16.37 30Slide11.jpg 920 7.85

TABLE 8 CN11 summary non-IS 26.21 IS 70.86 LV 97.07 IS/LV 73%

TABLE 9 CN12 raw values 1 Slide12.jpg 1562 2 Slide12.jpg 1059 8.81 3Slide12.jpg 485 4.04 4 Slide12.jpg 2925 5 Slide12.jpg 260 1.78 6Slide12.jpg 2159 14.76 7 Slide12.jpg 3492 8 Slide12.jpg 263 1.88 9Slide12.jpg 2886 20.66 10 Slide12.jpg 4855 11 Slide12.jpg 1992 16.00 12Slide12.jpg 2292 18.41 13 Slide12.jpg 2934 14 Slide12.jpg 1405 6.70 15Slide12.jpg 914 4.36 16 Slide12.jpg 2061 17 Slide12.jpg 81 0.51 18Slide12.jpg 1704 10.75 19 Slide12.jpg 2966 20 Slide12.jpg 105 0.71 21Slide12.jpg 2810 18.95 22 Slide12.jpg 4099 23 Slide12.jpg 823 5.02 24Slide12.jpg 2350 14.33 25 Slide12.jpg 3979 26 Slide12.jpg 357 3.50 27Slide12.jpg 2787 27.32 28 Slide12.jpg 2974 29 Slide12.jpg 490 2.31 30Slide12.jpg 2112 9.94

TABLE 10 CN12 summary non-IS 23.61 IS 71.76 LV 95.37 IS/LV 75%

TABLE 11 TNS1 raw values 1 Slide15.jpg 1857 2 Slide15.jpg 58 0.28 3Slide15.jpg 1672 8.10 4 Slide15.jpg 3383 5 Slide15.jpg 901 4.53 6Slide15.jpg 1873 9.41 7 Slide15.jpg 3460 8 Slide15.jpg 1452 13.43 9Slide15.jpg 2272 21.01 10 Slide15.jpg 3712 11 Slide15.jpg 772 8.32 12Slide15.jpg 2422 26.10 13 Slide15.jpg 3088 14 Slide15.jpg 498 3.87 15Slide15.jpg 1733 13.47 16 Slide15.jpg 1762 17 Slide15.jpg 65 0.33 18Slide15.jpg 1626 8.31 19 Slide15.jpg 3532 20 Slide15.jpg 2034 9.79 21Slide15.jpg 1206 5.80 22 Slide15.jpg 3411 23 Slide15.jpg 1752 16.44 24Slide15.jpg 1006 9.44 25 Slide15.jpg 4241 26 Slide15.jpg 2148 20.26 27Slide15.jpg 1101 10.38 28 Slide15.jpg 3440 29 Slide15.jpg 2307 16.10 30Slide15.jpg 165 1.15

TABLE 12 TNS1 summary non-IS 46.67 IS 56.59 LV 103.26 IS/LV 55%

TABLE 13 TNS2 raw values 1 Slide16.jpg 1565 2 Slide16.jpg 1058 7.44 3Slide16.jpg 145 1.02 4 Slide16.jpg 2654 5 Slide16.jpg 431 3.90 6Slide16.jpg 2043 18.47 7 Slide16.jpg 3247 8 Slide16.jpg 1053 8.43 9Slide16.jpg 1584 12.68 10 Slide16.jpg 3892 11 Slide16.jpg 2391 22.73 12Slide16.jpg 863 8.20 13 Slide16.jpg 2505 14 Slide16.jpg 1488 14.85 15Slide16.jpg 363 3.62 16 Slide16.jpg 1526 17 Slide16.jpg 9 0.06 18Slide16.jpg 1357 9.78 19 Slide16.jpg 2337 20 Slide16.jpg 16 0.16 21Slide16.jpg 1899 19.50 22 Slide16.jpg 3558 23 Slide16.jpg 1453 10.62 24Slide16.jpg 1504 10.99 25 Slide16.jpg 4041 26 Slide16.jpg 517 4.73 27Slide16.jpg 2763 25.30 28 Slide16.jpg 2946 29 Slide16.jpg 631 5.35 30Slide16.jpg 1326 11.25

TABLE 14 TNS2 summary non-IS 39.14 IS 60.41 LV 99.56 IS/LV 61%

TABLE 15 TNF1 raw values 1 Slide17.jpg 1326 2 Slide17.jpg 63 0.24 3Slide17.jpg 1183 4.46 4 Slide17.jpg 3158 5 Slide17.jpg 825 5.49 6Slide17.jpg 2014 13.39 7 Slide17.jpg 4805 8 Slide17.jpg 1774 12.92 9Slide17.jpg 1722 12.54 10 Slide17.jpg 4675 11 Slide17.jpg 1984 15.28 12Slide17.jpg 2470 19.02 13 Slide17.jpg 2754 14 Slide17.jpg 269 2.05 15Slide17.jpg 1377 10.50 16 Slide17.jpg 1373 17 Slide17.jpg 1067 3.89 18Slide17.jpg 43 0.16 19 Slide17.jpg 3113 20 Slide17.jpg 803 5.42 21Slide17.jpg 2008 13.55 22 Slide17.jpg 4657 23 Slide17.jpg 1189 8.94 24Slide17.jpg 2398 18.02 25 Slide17.jpg 4607 26 Slide17.jpg 1256 9.81 27Slide17.jpg 1978 15.46 28 Slide17.jpg 2769 29 Slide17.jpg 2115 16.04 30Slide17.jpg 72 0.55

TABLE 16 TNF1 summary non-IS 40.03 IS 53.82 LV 93.86 IS/LV 57%

TABLE 17 TNF2 raw values 1 Slide18.jpg 2133 2 Slide18.jpg 1861 12.21 3Slide18.jpg 239 1.57 4 Slide18.jpg 4037 5 Slide18.jpg 753 5.60 6Slide18.jpg 2304 17.12 7 Slide18.jpg 4663 8 Slide18.jpg 1548 10.62 9Slide18.jpg 2917 20.02 10 Slide18.jpg 5017 11 Slide18.jpg 2648 20.06 12Slide18.jpg 2480 18.78 13 Slide18.jpg 3629 14 Slide18.jpg 1698 13.10 15Slide18.jpg 348 2.69 16 Slide18.jpg 2130 17 Slide18.jpg 4 0.03 18Slide18.jpg 1988 13.07 19 Slide18.jpg 4108 20 Slide18.jpg 253 1.85 21Slide18.jpg 3796 27.72 22 Slide18.jpg 4612 23 Slide18.jpg 815 5.65 24Slide18.jpg 2427 16.84 25 Slide18.jpg 4880 26 Slide18.jpg 562 4.38 27Slide18.jpg 3535 27.53 28 Slide18.jpg 3507 29 Slide18.jpg 497 3.97 30Slide18.jpg 1837 14.67

TABLE 18 TNF2 summary non-IS 38.73 IS 80.00 LV 118.73 IS/LV 73%

TABLE 19 TNS3 raw values 1 Slide19.jpg 1484 2 Slide19.jpg 923 4.98 3Slide19.jpg 714 3.85 4 Slide19.jpg 3124 5 Slide19.jpg 990 6.65 6Slide19.jpg 1845 12.40 7 Slide19.jpg 3414 8 Slide19.jpg 1282 13.89 9Slide19.jpg 1833 19.87 10 Slide19.jpg 3380 11 Slide19.jpg 2123 16.33 12Slide19.jpg 1042 8.02 13 Slide19.jpg 2105 14 Slide19.jpg 957 7.73 15Slide19.jpg 308 2.49 16 Slide19.jpg 1524 17 Slide19.jpg 10 0.05 18Slide19.jpg 1530 8.03 19 Slide19.jpg 2860 20 Slide19.jpg 13 0.10 21Slide19.jpg 2293 16.84 22 Slide19.jpg 3358 23 Slide19.jpg 960 10.58 24Slide19.jpg 2639 29.08 25 Slide19.jpg 2538 26 Slide19.jpg 296 3.03 27Slide19.jpg 1797 18.41 28 Slide19.jpg 1992 29 Slide19.jpg 1105 9.43 30Slide19.jpg 401 3.42

TABLE 20 TNS3 summary non-IS 36.39 IS 61.20 LV 97.58 IS/LV 63%

TABLE 21 TNS4 raw values 1 Slide20.jpg 1524 2 Slide20.jpg 47 0.28 3Slide20.jpg 1417 8.37 4 Slide20.jpg 2478 5 Slide20.jpg 582 5.17 6Slide20.jpg 1617 14.36 7 Slide20.jpg 3284 8 Slide20.jpg 1226 11.20 9Slide20.jpg 2072 18.93 10 Slide20.jpg 3639 11 Slide20.jpg 771 7.20 12Slide20.jpg 2177 20.34 13 Slide20.jpg 3114 14 Slide20.jpg 491 5.36 15Slide20.jpg 2189 23.90 16 Slide20.jpg 1648 17 Slide20.jpg 1244 6.79 18Slide20.jpg 94 0.51 19 Slide20.jpg 2912 20 Slide20.jpg 1446 10.92 21Slide20.jpg 1262 9.53 22 Slide20.jpg 4073 23 Slide20.jpg 2350 17.31 24Slide20.jpg 1049 7.73 25 Slide20.jpg 3470 26 Slide20.jpg 2445 23.96 27Slide20.jpg 1052 10.31 28 Slide20.jpg 3219 29 Slide20.jpg 2120 22.39 30Slide20.jpg 32 0.34

TABLE 22 TNS4 summary non-IS 55.29 IS 57.16 LV 112.45 IS/LV 51%

TABLE 23 TNF3 raw values 1 Slide21.jpg 1551 2 Slide21.jpg 3 0.02 3Slide21.jpg 1502 10.65 4 Slide21.jpg 3054 5 Slide21.jpg 922 6.34 6Slide21.jpg 2049 14.09 7 Slide21.jpg 3374 8 Slide21.jpg 1280 12.52 9Slide21.jpg 1566 15.32 10 Slide21.jpg 2799 11 Slide21.jpg 1476 14.77 12Slide21.jpg 1061 10.61 13 Slide21.jpg 2330 14 Slide21.jpg 398 3.25 15Slide21.jpg 1012 8.25 16 Slide21.jpg 1689 17 Slide21.jpg 7 0.05 18Slide21.jpg 1544 10.06 19 Slide21.jpg 2894 20 Slide21.jpg 361 2.62 21Slide21.jpg 1925 13.97 22 Slide21.jpg 3254 23 Slide21.jpg 1137 11.53 24Slide21.jpg 1267 12.85 25 Slide21.jpg 2814 26 Slide21.jpg 1272 12.66 27Slide21.jpg 1113 11.07 28 Slide21.jpg 2821 29 Slide21.jpg 1438 9.69 30Slide21.jpg 174 1.17

TABLE 24 TNF3 summary non-IS 36.71 IS 54.02 LV 90.74 IS/LV 60%

TABLE 25 TNF4 raw values 1 Slide22.jpg 1354 2 Slide22.jpg 72 0.37 3Slide22.jpg 1335 6.90 4 Slide22.jpg 2892 5 Slide22.jpg 672 3.95 6Slide22.jpg 2093 12.30 7 Slide22.jpg 3414 8 Slide22.jpg 1342 9.83 9Slide22.jpg 2213 16.21 10 Slide22.jpg 3698 11 Slide22.jpg 1168 10.11 12Slide22.jpg 2317 20.05 13 Slide22.jpg 2565 14 Slide22.jpg 243 2.94 15Slide22.jpg 1398 16.90 16 Slide22.jpg 1486 17 Slide22.jpg 638 3.01 18Slide22.jpg 583 2.75 19 Slide22.jpg 2719 20 Slide22.jpg 26 0.16 21Slide22.jpg 2164 13.53 22 Slide22.jpg 3514 23 Slide22.jpg 568 4.04 24Slide22.jpg 2361 16.80 25 Slide22.jpg 3908 26 Slide22.jpg 1498 12.27 27Slide22.jpg 1805 14.78 28 Slide22.jpg 2946 29 Slide22.jpg 16 0.17 30Slide22.jpg 1969 20.72

TABLE 26 TNF4 summary non-IS 23.42 IS 70.46 LV 93.88 IS/LV 75%

TABLE 27 TNS5 raw values 1 Slide23.jpg 1615 2 Slide23.jpg 8 0.04 3Slide23.jpg 1571 8.75 4 Slide23.jpg 2789 5 Slide23.jpg 1477 11.65 6Slide23.jpg 1042 8.22 7 Slide23.jpg 3558 8 Slide23.jpg 2026 22.21 9Slide23.jpg 1327 14.55 10 Slide23.jpg 3822 11 Slide23.jpg 1044 8.74 12Slide23.jpg 1590 13.31 13 Slide23.jpg 3246 14 Slide23.jpg 1224 8.67 15Slide23.jpg 705 5.00 16 Slide23.jpg 1445 17 Slide23.jpg 1228 7.65 18Slide23.jpg 200 1.25 19 Slide23.jpg 2732 20 Slide23.jpg 1951 15.71 21Slide23.jpg 782 6.30 22 Slide23.jpg 3858 23 Slide23.jpg 3039 30.72 24Slide23.jpg 400 4.04 25 Slide23.jpg 3697 26 Slide23.jpg 2609 22.58 27Slide23.jpg 943 8.16 28 Slide23.jpg 3358 29 Slide23.jpg 1492 10.22 30Slide23.jpg 583 3.99

TABLE 28 TNS5 summary non-IS 69.10 IS 36.78 LV 105.88 IS/LV 35%

TABLE 29 TNS6 raw values 1 Slide24.jpg 1216 2 Slide24.jpg 258 1.49 3Slide24.jpg 770 4.43 4 Slide24.jpg 3079 5 Slide24.jpg 1436 10.26 6Slide24.jpg 1417 10.12 7 Slide24.jpg 3677 8 Slide24.jpg 2085 11.34 9Slide24.jpg 1122 6.10 10 Slide24.jpg 3908 11 Slide24.jpg 2151 15.96 12Slide24.jpg 1415 10.50 13 Slide24.jpg 2371 14 Slide24.jpg 1651 14.62 15Slide24.jpg 495 4.38 16 Slide24.jpg 1123 17 Slide24.jpg 879 5.48 18Slide24.jpg 262 1.63 19 Slide24.jpg 3090 20 Slide24.jpg 1775 12.64 21Slide24.jpg 1121 7.98 22 Slide24.jpg 3470 23 Slide24.jpg 2215 12.77 24Slide24.jpg 1219 7.03 25 Slide24.jpg 3666 26 Slide24.jpg 2524 19.97 27Slide24.jpg 1411 11.16 28 Slide24.jpg 2470 29 Slide24.jpg 1397 11.88 30Slide24.jpg 140 1.19

TABLE 30 TNS6 summary non-IS 58.20 IS 32.27 LV 90.47 IS/LV 36%

TABLE 31 CN13 raw values 1 Slide25.jpg 1010 2 Slide25.jpg 4 0.04 3Slide25.jpg 1006 8.96 4 Slide25.jpg 2216 5 Slide25.jpg 756 5.80 6Slide25.jpg 1708 13.10 7 Slide25.jpg 3122 8 Slide25.jpg 744 5.72 9Slide25.jpg 1674 12.87 10 Slide25.jpg 3214 11 Slide25.jpg 177 1.87 12Slide25.jpg 1678 17.75 13 Slide25.jpg 2504 14 Slide25.jpg 371 3.41 15Slide25.jpg 770 7.07 16 Slide25.jpg 940 17 Slide25.jpg 3 0.03 18Slide25.jpg 902 8.64 19 Slide25.jpg 1907 20 Slide25.jpg 266 2.37 21Slide25.jpg 1439 12.83 22 Slide25.jpg 2763 23 Slide25.jpg 1036 9.00 24Slide25.jpg 1855 16.11 25 Slide25.jpg 2930 26 Slide25.jpg 988 11.46 27Slide25.jpg 1618 18.78 28 Slide25.jpg 2498 29 Slide25.jpg 280 2.58 30Slide25.jpg 1839 16.93

TABLE 32 CN13 summary non-IS 21.14 IS 66.52 LV 87.66 IS/LV 76%

TABLE 33 CN14 raw values  1 Slide26.jpg 1387  2 Slide26.jpg 40 0.23  3Slide26.jpg 1356 7.82  4 Slide26.jpg 2994  5 Slide26.jpg 699 4.67  6Slide26.jpg 1620 10.82  7 Slide26.jpg 3017  8 Slide26.jpg 1087 11.89  9Slide26.jpg 1443 15.78 10 Slide26.jpg 2871 11 Slide26.jpg 2644 29.47 12Slide26.jpg 188 2.10 13 Slide26.jpg 2504 14 Slide26.jpg 7 0.05 15Slide26.jpg 1996 13.55 16 Slide26.jpg 1424 17 Slide26.jpg 490 2.75 18Slide26.jpg 931 5.23 19 Slide26.jpg 2926 20 Slide26.jpg 40 0.27 21Slide26.jpg 2231 15.25 22 Slide26.jpg 3248 23 Slide26.jpg 782 7.95 24Slide26.jpg 2137 21.71 25 Slide26.jpg 3401 26 Slide26.jpg 348 3.27 27Slide26.jpg 2624 24.69 28 Slide26.jpg 2079 29 Slide26.jpg 573 4.69 30Slide26.jpg 1042 8.52

TABLE 34 CN14 summary non-IS 32.62 IS 62.74 LV 95.36 IS/LV 66%

TABLE 35 TNF5 raw values  1 Slide27.jpg 1504  2 Slide27.jpg 22 0.13  3Slide27.jpg 1336 7.99  4 Slide27.jpg 2786  5 Slide27.jpg 390 3.22  6Slide27.jpg 1956 16.15  7 Slide27.jpg 3792  8 Slide27.jpg 1444 10.66  9Slide27.jpg 2232 16.48 10 Slide27.jpg 3470 11 Slide27.jpg 587 5.41 12Slide27.jpg 2824 26.04 13 Slide27.jpg 3002 14 Slide27.jpg 2361 16.52 15Slide27.jpg 1329 9.30 16 Slide27.jpg 1666 17 Slide27.jpg 274 1.48 18Slide27.jpg 1024 5.53 19 Slide27.jpg 2735 20 Slide27.jpg 9 0.08 21Slide27.jpg 2897 24.36 22 Slide27.jpg 3575 23 Slide27.jpg 1217 9.53 24Slide27.jpg 2163 16.94 25 Slide27.jpg 3350 26 Slide27.jpg 997 9.52 27Slide27.jpg 1812 17.31 28 Slide27.jpg 3022 29 Slide27.jpg 12 0.08 30Slide27.jpg 1778 12.36

TABLE 36 TNF5 summary non-IS 28.32 IS 76.23 LV 104.55 IS/LV 73%

TABLE 37 TNF6 raw values  1 Slide28.jpg 1114  2 Slide28.jpg 62 0.45  3Slide28.jpg 879 6.31  4 Slide28.jpg 2858  5 Slide28.jpg 459 3.85  6Slide28.jpg 1713 14.38  7 Slide28.jpg 3625  8 Slide28.jpg 369 3.56  9Slide28.jpg 2924 28.23 10 Slide28.jpg 3948 11 Slide28.jpg 511 4.27 12Slide28.jpg 2866 23.96 13 Slide28.jpg 3135 14 Slide28.jpg 386 3.08 15Slide28.jpg 1447 11.54 16 Slide28.jpg 1126 17 Slide28.jpg 10 0.07 18Slide28.jpg 1043 7.41 19 Slide28.jpg 3156 20 Slide28.jpg 160 1.22 21Slide28.jpg 3062 23.29 22 Slide28.jpg 3790 23 Slide28.jpg 827 7.64 24Slide28.jpg 2644 24.42 25 Slide28.jpg 3618 26 Slide28.jpg 1607 14.66 27Slide28.jpg 2452 22.36 28 Slide28.jpg 3440 29 Slide28.jpg 1023 7.43 30Slide28.jpg 1770 12.86

TABLE 38 TNF6 summary non-IS 23.11 IS 87.38 LV 110.50 IS/LV 79%

TABLE 39 TNS7 raw values  1 Slide29.jpg 1713  2 Slide29.jpg 607 4.61  3Slide29.jpg 782 5.93  4 Slide29.jpg 2484  5 Slide29.jpg 195 1.88  6Slide29.jpg 1842 17.80  7 Slide29.jpg 2807  8 Slide29.jpg 1568 12.29  9Slide29.jpg 380 2.98 10 Slide29.jpg 3271 11 Slide29.jpg 2187 20.06 12Slide29.jpg 350 3.21 13 Slide29.jpg 2309 14 Slide29.jpg 610 5.55 15Slide29.jpg 1008 9.17 16 Slide29.jpg 1923 17 Slide29.jpg 865 5.85 18Slide29.jpg 631 4.27 19 Slide29.jpg 3033 20 Slide29.jpg 1501 11.88 21Slide29.jpg 780 6.17 22 Slide29.jpg 3287 23 Slide29.jpg 2214 14.82 24Slide29.jpg 456 3.05 25 Slide29.jpg 3395 26 Slide29.jpg 2398 21.19 27Slide29.jpg 287 2.54 28 Slide29.jpg 2969 29 Slide29.jpg 1647 11.65 30Slide29.jpg 67 0.47

TABLE 40 TNS7 summary non-IS 54.88 IS 27.79 LV 82.68 IS/LV 34%

TABLE 41 TNS8 raw values  1 Slide30.jpg 1123  2 Slide30.jpg 11 0.05  3Slide30.jpg 988 4.40  4 Slide30.jpg 2352  5 Slide30.jpg 279 2.25  6Slide30.jpg 2001 16.16  7 Slide30.jpg 3274  8 Slide30.jpg 1085 7.29  9Slide30.jpg 1821 12.24 10 Slide30.jpg 3333 11 Slide30.jpg 2048 17.20 12Slide30.jpg 838 7.04 13 Slide30.jpg 2240 14 Slide30.jpg 793 7.08 15Slide30.jpg 840 7.50 16 Slide30.jpg 914 17 Slide30.jpg 866 4.74 18Slide30.jpg 64 0.35 19 Slide30.jpg 2811 20 Slide30.jpg 397 2.68 21Slide30.jpg 2135 14.43 22 Slide30.jpg 3378 23 Slide30.jpg 588 3.83 24Slide30.jpg 2250 14.65 25 Slide30.jpg 3241 26 Slide30.jpg 2671 23.08 27Slide30.jpg 287 2.48 28 Slide30.jpg 2697 29 Slide30.jpg 1247 9.25 30Slide30.jpg 23 0.17

TABLE 42 TNS8 summary non-IS 38.73 IS 39.71 LV 78.44 IS/LV 51%

TABLE 43 TNF7 raw values  1 Slide31.jpg 1733  2 Slide31.jpg 15 0.06  3Slide31.jpg 1704 6.88  4 Slide31.jpg 3401  5 Slide31.jpg 719 3.38  6Slide31.jpg 2216 10.43  7 Slide31.jpg 3789  8 Slide31.jpg 917 7.02  9Slide31.jpg 2163 16.56 10 Slide31.jpg 4149 11 Slide31.jpg 719 5.03 12Slide31.jpg 3423 23.93 13 Slide31.jpg 3309 14 Slide31.jpg 1479 8.49 15Slide31.jpg 1771 10.17 16 Slide31.jpg 1777 17 Slide31.jpg 1049 4.13 18Slide31.jpg 678 2.67 19 Slide31.jpg 3117 20 Slide31.jpg 221 1.13 21Slide31.jpg 2281 11.71 22 Slide31.jpg 3970 23 Slide31.jpg 2416 17.65 24Slide31.jpg 796 5.81 25 Slide31.jpg 4354 26 Slide31.jpg 3291 21.92 27Slide31.jpg 697 4.64 28 Slide31.jpg 3316 29 Slide31.jpg 2414 13.83 30Slide31.jpg 62 0.36

TABLE 44 TNF7 summary non-IS 41.32 IS 46.57 LV 87.90 IS/LV 53%

TABLE 45 TNF8 raw values 1 Slide32.jpg 1553 2 Slide32.jpg 572 2.58 3Slide32.jpg 873 3.93 4 Slide32.jpg 3334 5 Slide32.jpg 1084 5.53 6Slide32.jpg 1525 7.78 7 Slide32.jpg 4166 8 Slide32.jpg 2437 12.87 9Slide32.jpg 1557 8.22 10 Slide32.jpg 4558 11 Slide32.jpg 2698 20.13 12Slide32.jpg 1306 9.74 13 Slide32.jpg 3405 14 Slide32.jpg 2991 25.47 15Slide32.jpg 51 0.43 16 Slide32.jpg 1543 17 Slide32.jpg 3 0.01 18Slide32.jpg 1407 6.38 19 Slide32.jpg 3359 20 Slide32.jpg 581 2.94 21Slide32.jpg 2011 10.18 22 Slide32.jpg 3986 23 Slide32.jpg 202 1.11 24Slide32.jpg 3788 20.91 25 Slide32.jpg 4684 26 Slide32.jpg 425 3.08 27Slide32.jpg 3308 24.01 28 Slide32.jpg 3498 29 Slide32.jpg 920 7.63 30Slide32.jpg 1731 14.35

TABLE 46 TNF8 summary non-IS 40.68 IS 52.97 LV 93.65 IS/LV 57%

TABLE 47 TNS9 raw values  1 Slide33.jpg 2637  2 Slide33.jpg 14 0.06  3Slide33.jpg 2081 9.47  4 Slide33.jpg 4101  5 Slide33.jpg 1571 7.28  6Slide33.jpg 1516 7.02  7 Slide33.jpg 4527  8 Slide33.jpg 2519 18.36  9Slide33.jpg 1555 11.34 10 Slide33.jpg 3326 11 Slide33.jpg 3188 19.17 12Slide33.jpg 27 0.16 13 Slide33.jpg 2336 14 Slide33.jpg 1885 9.68 15Slide33.jpg 240 1.23 16 Slide33.jpg 2343 17 Slide33.jpg 2027 10.38 18Slide33.jpg 21 0.11 19 Slide33.jpg 3393 20 Slide33.jpg 1928 10.80 21Slide33.jpg 945 5.29 22 Slide33.jpg 4425 23 Slide33.jpg 2984 22.25 24Slide33.jpg 637 4.75 25 Slide33.jpg 3063 26 Slide33.jpg 773 5.05 27Slide33.jpg 1885 12.31 28 Slide33.jpg 2324 29 Slide33.jpg 1390 7.18 30Slide33.jpg 9 0.05

TABLE 48 TNS9 summary non-IS 55.11 IS 25.86 LV 80.97 IS/LV 32%

TABLE 49 TNS10 raw values 1 Slide34.jpg 1775 2 Slide34.jpg 1082 4.88 3Slide34.jpg 348 1.57 4 Slide34.jpg 3607 5 Slide34.jpg 1823 11.12 6Slide34.jpg 1483 9.05 7 Slide34.jpg 4313 8 Slide34.jpg 1087 6.80 9Slide34.jpg 2173 13.60 10 Slide34.jpg 4275 11 Slide34.jpg 2471 15.03 12Slide34.jpg 1734 10.55 13 Slide34.jpg 2864 14 Slide34.jpg 2424 18.62 15Slide34.jpg 43 0.33 16 Slide34.jpg 1601 17 Slide34.jpg 1600 8.00 18Slide34.jpg 16 0.08 19 Slide34.jpg 3486 20 Slide34.jpg 933 5.89 21Slide34.jpg 935 5.90 22 Slide34.jpg 4312 23 Slide34.jpg 3250 20.35 24Slide34.jpg 722 4.52 25 Slide34.jpg 4178 26 Slide34.jpg 3996 24.87 27Slide34.jpg 231 1.44 28 Slide34.jpg 3046 29 Slide34.jpg 2854 20.61 30Slide34.jpg 39 0.28

TABLE 50 TNS10 summary non-IS 68.08 IS 23.66 LV 91.74 IS/LV 26%

TABLE 51 TNF9 raw values 1 Slide35.jpg 1737 2 Slide35.jpg 841 2.91 3Slide35.jpg 788 2.72 4 Slide35.jpg 3368 5 Slide35.jpg 1416 7.99 6Slide35.jpg 1230 6.94 7 Slide35.jpg 4474 8 Slide35.jpg 1046 8.18 9Slide35.jpg 3356 26.25 10 Slide35.jpg 4877 11 Slide35.jpg 1303 6.68 12Slide35.jpg 3142 16.11 13 Slide35.jpg 3803 14 Slide35.jpg 2906 16.81 15Slide35.jpg 15 0.09 16 Slide35.jpg 1719 17 Slide35.jpg 8 0.03 18Slide35.jpg 1545 5.39 19 Slide35.jpg 3500 20 Slide35.jpg 9 0.05 21Slide35.jpg 3382 18.36 22 Slide35.jpg 4790 23 Slide35.jpg 9 0.07 24Slide35.jpg 4476 32.71 25 Slide35.jpg 4213 26 Slide35.jpg 1798 10.67 27Slide35.jpg 2840 16.85 28 Slide35.jpg 3714 29 Slide35.jpg 2917 17.28 30Slide35.jpg 342 2.03

TABLE 52 TNF9 summary non-IS 35.33 IS 63.72 LV 99.05 IS/LV 64%

TABLE 53 TNF10 raw values 1 Slide36.jpg 2294 2 Slide36.jpg 14 0.08 3Slide36.jpg 2183 12.37 4 Slide36.jpg 4093 5 Slide36.jpg 189 1.34 6Slide36.jpg 3572 25.31 7 Slide36.jpg 4330 8 Slide36.jpg 829 9.38 9Slide36.jpg 2710 30.67 10 Slide36.jpg 2189 11 Slide36.jpg 185 1.18 12Slide36.jpg 1581 10.11 13 Slide36.jpg 1961 14 Slide36.jpg 344 1.40 15Slide36.jpg 1293 5.27 16 Slide36.jpg 2188 17 Slide36.jpg 1766 10.49 18Slide36.jpg 382 2.27 19 Slide36.jpg 4243 20 Slide36.jpg 2206 15.08 21Slide36.jpg 1246 8.52 22 Slide36.jpg 4883 23 Slide36.jpg 3763 37.76 24Slide36.jpg 583 5.85 25 Slide36.jpg 2162 26 Slide36.jpg 2025 13.11 27Slide36.jpg 18 0.12 28 Slide36.jpg 2558 29 Slide36.jpg 1179 3.69 30Slide36.jpg 615 1.92

TABLE 54 TNF10 summary non-IS 46.76 IS 51.20 LV 97.96 IS/LV 52%

TABLE 55 Composite image data IS/LV IS/LV IS/LV IS/LV CON7 70% TMZ3 64%TNF1 57% TNS1 55% CONS 65% TMZ1 68% TNF2 67% TNS2 61% CON6 75% TMZ2 60%TNF3 60% TNS3 63% CON4 65% TMZ7 43% TNF4 75% TNS4 51% CON3 64% TMZ8 51%TNF5 73% TNS5 35% CON1 77% TMZ5 58% TNF6 79% TNS6 36% CON2 55% TMZ6 49%TNF7 53% TNS7 34% CON8 68% TMZ9 44% TNF8 57% TNS8 51% CON9 67% TMZ10 49%TNF9 64% TNS9 31% CON10 62% TMZ4 71% TNF10 52% TNS10 26% CON11 73% CON1275% CON13 76% CON14 66% Mean 68% Mean 56% Mean 64% Mean 44% SD  6% SD10% SD 10% SD 13% SE  2% SE  3% SE  3% SE  4% TTEST 8.77E−04 1.61E−014.79E−06 TMZ/TNS 4.00E−02

The results show that a combination of trimetazidine, nicotinamide, andsuccinate at 20 μM preserved coronary flow and cardiac functionalrecovery and decreased infarct size in isolated hearts afterischemia-reperfusion. This combination was more effective in decreasinginfarct size than TMZ alone. A combination of trimetazidine,nicotinamide, and succinate at 2 μM did not appear to decreasemyocardial ischemia-reperfusion injury.

This study suggested that the combination of trimetazidine,nicotinamide, and succinate at 20 μM generated better protection againstischemia-reperfusion injury in Langendorff system.

FIG. 43 is a schematic of the method used to analyze the effects ofcompositions of the invention on cardiac function. Following transverseaortic constriction (TAC) or a sham procedure, mice were given one ofthe following via an osmotic mini-pump: CV8814 at 5.85 mg/kg/day (CV4);CV8814 at 5.85 mg/kg/day, nicotinic acid at 1.85 mg/kg/day, andsuccinate at 2.43 mg/kg/day (TV8); or saline (SA). Echocardiograms weremeasured immediately following TAC, three weeks after TAC, and 6 weeksafter TAC. Mice were sacrificed at 6 weeks, and tissues were analyzed.

FIG. 44 shows hearts from mice six weeks after a sham procedure (SHAM),TAC followed by saline administration (TAC), TAC followed by CV4administration (CV4), or TAC followed by TV8 administration.

FIG. 45 is of graph of heart weight relative to body weight six weeksafter transverse aortic constriction. Treatments are as indicated inrelation to FIG. 44.

FIG. 46 is graph of heart weight six weeks after transverse aorticconstriction. Treatments are as indicated in relation to FIG. 44.

FIG. 47 shows graphs of fractional shortening (FS) and ejection fraction(EF) at indicated time points after transverse aortic constriction.Treatments are as indicated in relation to FIG. 44.

FIG. 48 is a graph of left ventricular end-systolic diameter atindicated time points after transverse aortic constriction. Treatmentsare as indicated in relation to FIG. 44.

FIG. 49 is a graph of intraventricular septal dimension at indicatedtime points after transverse aortic constriction. Treatments are asindicated in relation to FIG. 44.

FIG. 50 is a graph of left ventricular mass at indicated time pointsafter transverse aortic constriction. Treatments are as indicated inrelation to FIG. 44.

FIG. 51 is a graph of isovolumic relaxation time at indicated timepoints after transverse aortic constriction. Treatments are as indicatedin relation to FIG. 44.

FIG. 52 is a graph of the ratio peak velocity flow in early diastole vs.late diastole at indicated time points after transverse aorticconstriction. Treatments are as indicated in relation to FIG. 44.

FIG. 53 is a graph of left ventricular developed pressure at six weeksafter transverse aortic constriction. Treatments are as indicated inrelation to FIG. 44.

FIG. 54 is a graph of the rate of left ventricle pressure rise at sixweeks after transverse aortic constriction. Treatments are as indicatedin relation to FIG. 44.

Chemical Synthesis Schemes.

Compounds of the invention include2-(4-(2,3,4-trimethoxybenzyl)piperazin-1-yl)ethan-1-ol (referred toherein as CV8814) and 2-(4-(2,3,4-trimethoxybenzyl)piperazin-1-yl)ethylnicotinate (referred to herein as CV-8972). These compounds may besynthesized according to the following scheme:

Stage 1:

Stage 2:

Stage 3:

The product was converted to the desired polymorph by recrystallization.The percentage of water and the ratio of methanol:methyl ethyl ketone(MEK) were varied in different batches using 2.5 g of product.

In batch MBA 25, 5% water w/r/t total volume of solvent (23 volumes)containing 30% methanol:70% MEK was used for precipitation. The yieldwas 67% of monohydrate of CV-8972. Water content was determined by KF tobe 3.46%.

In batch MBA 26, 1.33% water w/r/t total volume of solvent (30 volumes)containing 20% methanol:80% MEK was used for precipitation. The yieldwas 86.5% of monohydrate of CV-8972. Water content was determined by KFto be 4.0%. The product was dried under vacuum at 40° C. for 24 hours todecrease water content to 3.75%.

In batch MBA 27, 3% water w/r/t total volume of solvent (32 volumes)containing 22% methanol:78% MEK was used for precipitation. The yieldwas 87.22% of monohydrate of CV-8972. Water content was determined by KFto be 3.93% after 18 hours of drying at room temperature under vacuum.The product was further dried under vacuum at 40° C. for 24 hours todecrease water content to 3.54%.

In other batches, the ratio and total volume of solvent were heldconstant at 20% methanol:80% MEK and 30 volumes in batches using 2.5 gof product, and only the percentage of water was varied.

In batch MBA 29, 1.0 equivalent of water was added. Material wasisolated and dried under vacuum at 40° C. for 24 hours. Water contentwas determined by KF to be 0.89%, showing that the monohydrate form wasnot forming stoichiometrically.

In batch MBA 30, 3% water was added. Material was isolated and driedunder vacuum at 40° C. for 24 hours. Water content was determined by KFto be 3.51%, showing that monohydrate is forming with addition of excesswater.

In batch MBA 31, 5% water was added. Material was isolated and driedunder vacuum at 40° C. for 24 hours. Water content was determined by KFto be 3.30%, showing that monohydrate is forming with addition of excesswater.

Results are summarized in Table 56.

TABLE 56 Water Amount of percentage KF result Water used theoretical KF(Sample for reaction (for result after drying (based Yield Drying Dryingmonohydrate (% of at 40° C. for on total Ratio of Total obtained Timetemperature Sample preparation) water) 24 hours) volume) MeOH:MEK Volume(%) (hr) (° C.) 289-MBA-25 3.32% 3.46 — 5% 30-70 23 vol 67.6 24 22289-MBA-26 3.32% 4.00 3.75 1.33%   20-80 30 vol 86.5 19 23 289-MBA-273.32% 3.93 3.54 3% 22-78 32 vol 87.22 18 23 289-MBA-29 3.32% — 0.89 1.0eq based 20-80 30 vol 84 24 40 on input weight 289-MBA-30 3.32% — 3.513% 20-80 30 vol 90 24 40 289-MBA-31 3.32% — 3.30 5% 20-80 30 vol 81 2440

Metabolism of Compounds in Dogs

The metabolism of various compounds was analyzed in dogs.

FIG. 55 is a graph showing levels of CV-8814 (solid triangles, solidlines) and trimetazidine (open triangles, dashed lines) afterintravenous administration of CV-8834 at 2.34 mg/kg. CV-8834 is acompound of formula (II) in which y=1.

FIG. 56 is a graph showing levels of CV-8814 (solid triangles, solidlines) and trimetazidine (open triangles, dashed lines) after oraladministration of CV-8834 at 77.4 mg/kg.

FIG. 57 is a graph showing levels of CV-8814 (solid triangles, solidlines) and trimetazidine (open triangles, dashed lines) after oraladministration of CV-8834 at 0.54 mg/kg.

FIG. 58 is a graph showing levels of CV-8814 (solid triangles, solidlines) and trimetazidine (open triangles, dashed lines) after oraladministration of CV-8834 at 1.08 mg/kg.

FIG. 59 is a graph showing levels of CV-8814 (solid triangles, solidlines) and trimetazidine (open triangles, dashed lines) after oraladministration of CV-8834 at 2.15 mg/kg.

Data from FIGS. 55-59 is summarized in Table 57.

TABLE 57 Route Dose AUC₀₋₈ of (mg/ T_(max) C_(max) (ng × Compound admin.kg) Analyte (hours) (ng/mL) hr/mL) % F CV-8834 PO 77.4 8814 0.75 1210038050 69 CV-8834 PO 77.4 TMZ 1.67 288 1600 72 CV-8834 IV 2.34 8814 0.083974 1668 — CV-8834 IV 2.34 TMZ 2.67 13.4 66.7 — CV-8834 PO 0.54 8814 0.574.0 175 45 CV-8834 PO 0.54 TMZ 1.17 3.63 17.6 >100 CV-8834 PO 1.08 88140.5 136 335 44 CV-8834 PO 1.08 TMZ 0.866 6.19 30.4 99 CV-8834 PO 2.158814 0.583 199 536 35 CV-8834 PO 2.15 TMZ 1.17 9.80 51.6 84

FIG. 60 is a graph showing levels of trimetazidine after oraladministration of CV-8972 at 1.5 mg/kg (triangles) or intravenousadministration of trimetazidine at 2 mg/kg (squares).

FIG. 61 is a graph showing levels of CV-8814 after oral administrationof CV-8972 at 1.5 mg/kg (triangles) or intravenous administration ofCV-8814 at 2.34 mg/kg (squares).

FIG. 62 is a graph showing levels of CV-8814 after intravenousadministration of CV-8834 at 4.3 mg/kg (squares) or oral administrationof CV-8834 at 2.15 mg/kg (triangles).

FIG. 63 is a graph showing levels of CV-8814 after intravenousadministration of CV-8814 at 2.34 mg/kg (squares) or oral administrationof CV-8814 at 2.34 mg/kg (triangles).

Data from FIGS. 60-63 is summarized in Table 58.

TABLE 58 Route of Dose T_(max) C_(max) AUC₀₋₂₄ Compound admin. (mg/kg)Vehicle Fasted Analyte (hours) (ng/mL) (ng × hr/mL) % F CV-8972 PO 1.5 —— TMZ 2.0 17.0 117 4.3%  TMZ IV 2 0.9% NaCl 8 hrs TMZ 0.083 1002 3612 —CV-8972 PO 1.5 — — 8814 1.125 108 534 27% CV-8814 IV 2.34 0.9% NaCl 8hrs 8814 0.083 1200 3059 — CV-8834 PO 4.3 0.9% NaCl 8 hrs 8814 1.0 6922871 69% CV-8834 IV 4.3 0.9% NaCl 8 hrs 8814 0.083 1333 4154 — CV-8834PO 4.3 0.9% NaCl 8 hrs 8814 1.0 692 2871 51% CV-8814 IV 2.34 0.9% NaCl 8hrs 8814 0.083 1200 3059 — CV-8814 PO 2.34 0.9% NaCl 8 hrs 8814 0.333672 1919 63% CV-8814 IV 2.34 0.9% NaCl 8 hrs 8814 0.083 1200 3059 —

Effect of CV-8814 on Enzyme Activity

The effect of CV-8814 on the activity of various enzymes was analyzed inin vitro assays. Enzyme activity was assayed in the presence of 10 μMCV-8814 using conditions of time, temperature, substrate, and bufferthat were optimized for each enzyme based on published literature.Inhibition of 50% or greater was not observed for any of the followingenzymes: ATPase, Na⁺/K⁺, pig heart; Cholinesterase, Acetyl, ACES, human;Cyclooxygenase COX-1, human; Cyclooxygenase COX-2, human; MonoamineOxidase MAO-A, human; Monoamine Oxidase MAO-B, human; Peptidase,Angiotensin Converting Enzyme, rabbit; Peptidase, CTSG (Cathepsin G),human; Phosphodiesterase PDE3, human; Phosphodiesterase PDE4, human;Protein Serine/Threonine Kinase, PKC, Non-selective, rat; ProteinTyrosine Kinase, Insulin Receptor, human; Protein Tyrosine Kinase, LCK,human; Adenosine A1, human; Adenosine A_(2A), human; Adrenergic α_(1A),rat; Adrenergic α_(1B), rat; Adrenergic α_(1D), human; Adrenergicα_(2A), human; Adrenergic α_(2B), human; Adrenergic β₁, human;Adrenergic β₂, human; Androgen (Testosterone), human; Angiotensin AT₁,human; Bradykinin B₂, human; Calcium Channel L-Type, Benzothiazepine,rat; Calcium Channel L-Type, Dihydropyridine, rat; Calcium ChannelL-Type, Phenylalkylamine, rat; Calcium Channel N-Type, rat; CannabinoidCB₁, human; Cannabinoid CB₂, human; Chemokine CCR1, human; ChemokineCXCR2 (IL-8R_(B)), human; Cholecystokinin CCK₁ (CCK_(A)), human;Cholecystokinin CCK₂ (CCK_(B)), human; Dopamine D₁, human; DopamineD_(2L), human; Dopamine D_(2S), human; Endothelin ET_(A), human;Estrogen ERα, human; GABA_(A), Chloride Channel, TBOB, rat; GABA_(A),Flunitrazepam, Central, rat; GABA_(A), Ro-15-1788, Hippocampus, rat;GABA_(B1A), human; Glucocorticoid, human; Glutamate, AMPA, rat;Glutamate, Kainate, rat; Glutamate, Metabotropic, mGlu5, human;Glutamate, NMDA, Agonism, rat; Glutamate, NMDA, Glycine, rat; Glutamate,NMDA, Phencyclidine, rat; Glutamate, NMDA, Polyamine, rat; Glycine,Strychnine-Sensitive, rat; Histamine H₁, human; Histamine H₂, human;Melanocortin MC₁, human; Melanocortin MC₄, human; Muscarinic M₁, human;Muscarinic M₂, human; Muscarinic M₃, human; Muscarinic M₄, human;Neuropeptide Y Y₁, human; Nicotinic Acetylcholine, human; NicotinicAcetylcholine α1, Bungarotoxin, human; Opiate δ₁ (OP1, DOP), human;Opiate κ (OP2, KOP), human; Opiate μ (OP3, MOP), human; PlateletActivating Factor (PAF), human; Potassium Channel [KATP], hamster;Potassium Channel hERG, human; PPARγ, human; Progesterone PR-B, human;Serotonin (5-Hydroxytryptamine) 5-HT_(1A), human; Serotonin(5-Hydroxytryptamine) 5-HT_(1B), human; Serotonin (5-Hydroxytryptamine)5-HT_(2A), human; Serotonin (5-Hydroxytryptamine) 5-HT_(2B), human;Serotonin (5-Hydroxytryptamine) 5-HT_(2C), human; Serotonin(5-Hydroxytryptamine) 5-HT₃, human; Sodium Channel, Site 2, rat;Tachykinin NK₁, human; Transporter, Adenosine, guinea pig; Transporter,Dopamine (DAT), human; Transporter, GABA, rat; Transporter,Norepinephrine (NET), human; Transporter, Serotonin(5-Hydroxytryptamine) (SERT), human; and Vasopressin V_(1A), human.

Analysis of CV-8972 Batch Properties

CV-8972 (2-(4-(2,3,4-trimethoxybenzyl)piperazin-1-yl)ethyl nicotinate,HCl salt, monohydrate) was prepared and analyzed. The batch wasdetermined to be 99.62% pure by HPLC.

FIG. 64 is a graph showing the HPLC elution profile of a batch ofCV-8972.

FIG. 65 is a graph showing analysis of molecular species present in abatch of CV-8972.

FIG. 66 is a pair of graphs showing HPLC elution profiles of molecularspecies present in a batch of CV-8972.

FIG. 67 is a pair of graphs showing HPLC elution profiles of molecularspecies present in a batch of CV-8972.

FIG. 68 is a graph showing X-ray powder diffraction analysis of a batchof CV-8972.

FIG. 69 is a graph showing X-ray powder diffraction analysis of batchesof CV-8972. Batch 289-MBA-15-A, shown in blue, contains form B ofCV-8972, batch 276-MBA-172, shown in black contains form A of CV-8972,and batch 289-MBA-16, shown in red, contains a mixture of forms A and B.

FIG. 70 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of batch 276-MBA-172 of CV-8972.

FIG. 71 is a graph showing dynamic vapor sorption (DVS) of batch276-MBA-172 of CV-8972.

FIG. 72 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of batch 289-MBA-15-A of CV-8972.

FIG. 73 is a graph showing dynamic vapor sorption (DVS) of batch289-MBA-15-A of CV-8972.

FIG. 74 is a graph showing X-ray powder diffraction analysis of samplesof CV-8972. A pre-DVS sample from batch 276-MBA-172 is shown in blue, apre-DVS sample from batch 289-MBA-15-A is shown in red, and a post-DVSsample from batch 289-MBA-15-A is shown in black.

FIG. 75 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of batch 289-MBA-16 of CV-8972.

FIG. 76 is a graph showing X-ray powder diffraction analysis of samplesof CV-8972. Form B is shown in green, form A is shown in blue, a samplefrom an ethanol slurry of batch 289-MBA-15-A is shown in red, and asample from an ethanol slurry of batch 289-MBA-16 is shown in black.

The stability of CV-8972 was analyzed.

Samples from batch 289-MBA-15-A (containing form B) were added tovarious solvents, incubated under various conditions, and analyzed byX-ray powder diffraction. Results are summarized in Table 59.

TABLE 59 Solvent Conditions XRPD results EtOH Slurry, RT, 3 d Form A +Form B MeOH/H2O (95:5) Slurry, RT, 5 d Form A A_(w) = 0.16 IPA/H2O(98:2) Slurry, RT, 5 d Form A A_(w) = 0.26 MeOH/H2O (80:20) Slurry, RT,5 d Form A A_(w) = 0.48 EtOH/H2O (90:10) Slurry, RT, 5 d Form A A_(w) =0.52 IPA/H2O (90:10) Slurry, RT, 5 d Form A A_(w) = 0.67 Acetone/H2O(90:10) Slurry, RT, 5 d Form A A_(w) = 0.72 ACN/H2O (90:10) Slurry, RT,5 d Form A A_(w) = 0.83 EtOAc/H2O (97:3) Slurry, RT, 5 d Form A A_(w) =0.94) MeOH Slurry, RT, 5 d Form A + Form B EtOAc Slurry, RT, 5 d FormA + Form B MEK Slurry, RT, 5 d Form A — 100° C., Form B, shifted withminor 20 minutes Form A EtOH CC from 60° C. Form C + minor Form A

Samples from batch 289-MBA-16 (containing forms A and B) were added tovarious solvents, incubated under various conditions, and analyzed byX-ray powder diffraction. Results are summarized in Table 60.

TABLE 60 Solvent Conditions XRPD results EtOH Slurry, RT, 3 d Form A +Form B MeOH Vapor diffusion w/ MTBE Form A EtOAc Attempted to dissolveat ~60° C., Form A + Form B solids remained, cooled slowly to RT, letstir at RT from 60° C.

FIG. 77 is a graph showing X-ray powder diffraction analysis of samplesof CV-8972. A sample containing form B is shown in blue, a samplecontaining form A is shown in red, and a sample containing a mixture offorms A and C is shown in black.

The stability of CV-8972 was analyzed. Aqueous samples containingCV-8972 at different concentrations and pH were incubated for variousperiods and analyzed. Results are shown in Table 61.

TABLE 61 Decrease in purity of CV-8972 Time Retention Time between timeSample (hrs) pH 2.2 2.6 4.2 4.7 5.6 points 276-MBA-172 0 6.6 3.39 0.60.23 0.54 95.24 10 mg/mL pH 6 1 6.8 4.81 0.81 0.23 0.73 93.43 1.81 (FormA) 4 6.8 5.72 0.9 0.21 0.83 91.82 1.61 6 6.7 6.45 0.81 ND 0.93 91.8 0.0222 6.7 7.38 1.54 0.13 1.11 89.66 2.14 276-MBA-172 0 6.1 ND ND 1.29 ND98.01  2 mg/mL pH 6 1 6.1 1.5 ND 1.28 ND 97.22 0.79 (Form A) 4 6.1 2.03ND 0.95 ND 97.01 0.21 6 6.1 2.47 ND 1.02 ND 96.51 0.5 22 6.1289-MBA-15-A 0 6 3.3 0.6 0.26 0.48 95.36 10 mg/mL pH 6 1 6.1 3.76 0.650.25 0.53 94.81 0.55 (Form B) 4 6 3.97 0.59 0.19 0.56 94.69 0.12 6 5.94.3 0.54 0.17 0.6 94.39 0.3 22 5.9 4.53 0.69 0.19 0.65 93.93 0.46289-MBA-15-A 0 6.9 1.33 ND 1.19 ND 97.48  2 mg/mL pH 6 1 6.9 3.73 ND1.17 ND 95.1 2.38 (Form B) 4 6.8 5.25 0.67 0.84 0.79 92.45 2.65 6 6.86.63 0.9 0.83 0.99 90.65 1.8 22 6.7 7.72 1.13 0.86 1.14 89.15 1.5276-MBA-172 0 7.1 5.9 0.94 0.22 0.78 92.85 10 mg/mL pH 7 1 7.2 8.12 1.450.21 1.17 89.05 3.8 (Form A) 4 7.1 10.14 1.48 0.13 1.46 86.8 2.25 6 7.111.63 1.78 0.13 1.67 84.79 2.01 22 7 276-MBA-172 0 6.7 1.42 ND 1.05 ND97.53  2 mg/mL pH 7 1 6.8 3.31 ND 1.06 0.57 95.06 2.47 (Form A) 4 6.74.21 0.58 0.82 0.69 93.7 1.36 6 6.7 5.63 0.67 0.74 0.85 92.12 1.58 226.8 6.26 0.85 0.85 0.98 91.07 1.05 289-MBA-15-A 0 7.4 6.2 1.16 0.27 0.8791.5 10 mg/mL pH 7 1 7.4 10.47 1.65 0.25 1.44 86.18 5.32 (Form B) 4 7.413.64 1.93 0.19 1.89 82.36 3.82 6 7.3 15.66 2.57 0.2 0.2 79.37 2.99 227.1 289-MBA-15-A 0 6.5 1.62 ND 0.9 ND 97.48  2 mg/mL pH 7 1 6.6 3.16 ND0.89 0.49 95.46 2.02 (Form B) 4 6.5 4.27 0.53 0.66 0.62 93.92 1.54 6 6.522 6.5

Samples from batch S-18-0030513 (containing form A) were added tovarious solvents, incubated under various conditions, and analyzed byX-ray powder diffraction. Results are summarized in Table 62.

TABLE 62 Solvent Conditions XRPD results CHCl3 Slurry, RT Form A EtOAcSlurry, RT Form A THF Slurry, RT Form A — VO, RT Form A —  80° C., 20minutes Form A with slight peak shifting — 100° C., 20 minutes Form B +Form A, shifted — 97% RH Stress of Form A Form A dried at 80° C. for 20min EtOH Crash cool from Form A + Form C 70° C. MEK/H2O 99:1 Slow coolfrom Form A 70° C.

Samples from batch 289-MBA-16 (containing forms A and B) were added tovarious solvents, incubated under various conditions, and analyzed byX-ray powder diffraction. Results are summarized in Table 63.

TABLE 63 Solvent Conditions XRPD results EtOH Slurry, RT, 3 d Form A +Form B MeOH VD w/ MTBE Form A EtOAc SC from 60° C. Form A + Form B THFSC from 60° C. Form B EtOH SC from 60° C. Form A + Form C MeOH/H2OSlurry, overnight, 1 g scale Form A (95:5)

FIG. 78 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of samples containing form A of CV-8972. A samplefrom an ethanol acetate-water slurry is shown with solid lines, a samplefrom a methanol-water slurry is shown with regularly-dashed lines, and asample from an ethanol-water slurry is shown with dashed-dotted lines.

FIG. 79 is a graph showing differential scanning calorimetry and thermalgravimetric analysis of a sample containing form A of CV-8972. Prior toanalysis, the sample was dried at 100° C. for 20 minutes.

Samples containing form A of CV-8972 were analyzed for stability inresponse to humidity. Samples were incubated at 40° C., 75% relativehumidity for various periods and analyzed. Results are shown in Table64.

TABLE 64 Retention Time Time (days) 1.9 3.9 4.5 5.4 0 ND 1.16 ND 98.84 1ND 0.68 ND 99.32 7 0.63 0.14 0.12 99.12

Form A of CV-8972 were analyzed for stability in aqueous solution.Aqueous samples containing CV-8972 at different concentrations and pHwere incubated for various periods and analyzed. Results are shown inTable 65.

TABLE 65 % change Concentration Time Retention Time from t0 of CV-8972(hrs) 1.9 2.2 3.9 4.5 5.4 of RT 5.4   21 mg/mL, 0 ND ND 1.12 ND 98.88 —Initial 1 1.03 ND 0.94 ND 98.03 −0.86 pH = 2.0 2 1.9 ND 1 ND 97.11 −1.796 5.25 0.83 0.96 0.78 92.18 −6.78 12.5 mg/mL, 0 ND ND 1.79 ND 98.21 —Initial 1 1.38 ND 1.41 ND 97.21 −1.02 pH = 2.1 2 2.43 ND 1.67 ND 95.9−2.35 6 6.59 1.04 1.74 1.04 89.58 −8.79  4.2 mg/mL, 0 ND ND 5.35 ND94.65 — Initial 1 ND ND 4.02 ND 95.98 1.41 pH = 2.3 2 3.72 ND 5.09 ND91.19 −3.66 6 9.71 ND 5.3 ND 84.99 −10.21

The amount of CV-8972 present in various dosing compositions wasanalyzed. Results are shown in Table 66.

TABLE 66 Vol. Total pH addl. Target Vol. Initial Vol. vol. after 1NFinal Dose API Mass pH 1N base base NaOH Dose (mg/ soln. CV8972 API NaOHsoln. soln. added (mg/ mL) (mL) (mg) soln. (mL) (mL) addn. (mL) mL) 1030 779.06 2.0 2.07 30 3.6 0.7 9.92 2 30 157.38 2.4 0.19 30 2.8 0.35 2.0210 50 777.05 2.1 2.77 10 6.2 — 10.01 2 50 142.08 2.5 0.99 10 3.0 0.31.82

Brain-to-Plasma Ratio of Compounds In Vivo

The brain-to-plasma ratio of trimetazidine and CV-8814 was analyzedafter intravenous administration of the compounds to rats. Dosingsolutions were analyzed by liquid chromatography tandem massspectrometry (LC-MS/MS). Results are shown in Table 67.

TABLE 67 Measured Nominal Dosing Dosing Solution Test Route of Conc.Conc. % of Article Administration Vehicle (mg/mL) (mg/mL) Nominal TMZ IVNormal 1.0 1.14 114 Saline* CV-8814 IV Normal 0.585 0.668 114 Saline*

The concentrations of compounds in the brain and plasma were analyzed 2hours after administering compounds at 1 mg/kg to rats. Results fromtrimetazidine-treated rats are shown in Table 68. Results fromCV-8814-treated rats are shown in Table 69.

TABLE 68 TMZ-treated rats Rat # 11 12 13 Brain Weight (g) 1.781 1.7751.883 Brain Homogenate Volume 8.91 8.88 9.42 (mL) Brain Homogenate Conc.7.08 7.35 7.90 (ng/mL) Brain Tissue Conc. (ng/g) 35.4 36.8 39.5 PlasmaConc. (ng/g)¹ 22.7 14.0 14.1 B:P Ratio 1.56 2.63 2.80

TABLE 69 CV-8814-treated rats Rat # 14 15 16 Brain Weight (g) 1.8571.902 2.026 Brain Homogenate Volume 9.29 9.51 10.1 (mL) Brain HomogenateConc. 4.01 4.21 4.74 (ng/mL) Brain Tissue Conc. (ng/g) 20.1 21.1 24Plasma Conc. (ng/g)¹ 19.3 17.0 14.0 B:P Ratio 1.04 1.24 1.693

The average B:P ratio for trimetazidine-treated rats was 2.33±0.672. Theaverage B:P ratio for trimetazidine-treated rats was 1.32±0.335.

INCORPORATION BY REFERENCE

References and citations to other documents, such as patents, patentapplications, patent publications, journals, books, papers, webcontents, have been made throughout this disclosure. All such documentsare hereby incorporated herein by reference in their entirety for allpurposes.

EQUIVALENTS

Various modifications of the invention and many further embodimentsthereof, in addition to those shown and described herein, will becomeapparent to those skilled in the art from the full contents of thisdocument, including references to the scientific and patent literaturecited herein. The subject matter herein contains important information,exemplification and guidance that can be adapted to the practice of thisinvention in its various embodiments and equivalents thereof.

1. A compound represented by formula (VII):A-C  (VII), wherein: A comprises a compound that shifts cardiacmetabolism from fatty acid oxidation to glucose oxidation; and C is aNAD⁺ precursor molecule.
 2. The compound of claim 1, wherein C iscovalently linked to A.
 3. The compound of claim 2, wherein A isPEGylated with an ethylene glycol moiety.
 4. The compound of claim 3,wherein the ethylene glycol moiety comprises (CH₂CH₂O)_(x), whereinx=1-15.
 5. The compound of claim 4, wherein the covalent linkage is viathe ethylene glycol moiety.
 6. The compound of claim 4, wherein thecovalent linkage is not via the ethylene glycol moiety.
 7. The compoundof claim 1, wherein A is selected from the group consisting oftrimetazidine, etomoxir, perhexiline, a PPAR agonist, a malonyl CoAdecarboxylase inhibitor, and dichloroacetate.
 8. The compound of claim1, wherein C is selected from the group consisting of nicotinic acid,nicotinamide, and nicotinamide ribo side.
 9. The compound of claim 8,wherein C is nicotinic acid.
 10. The compound of claim 5, wherein thecompound that shifts cardiac metabolism from fatty acid oxidation toglucose oxidation is a PEGylated form of trimetazidine.
 11. The compoundof claim 10, wherein C is nicotinic acid that is covalently linked tothe PEGylated form of trimetazidine.
 12. The compound of claim 11,wherein the nicotinic acid is covalently linked to the PEGylated form oftrimetazidine via the PEGylated moiety.
 13. The compound of claim 12,wherein the compound is represented by formula (X):


14. The compound of claim 11, wherein the nicotinic acid is covalentlylinked to the PEGylated form of trimetazidine via the trimetazidinemoiety.
 15. The compound of claim 1, wherein A is trimetazidine that iscovalently linked to C, which is nicotinic acid.
 16. A compoundrepresented by formula (VIII):A-L-C  (VIII), wherein: A is a compound that shifts cardiac metabolismfrom fatty acid oxidation to glucose oxidation; L is a linker; and C isa NAD⁺ precursor molecule.
 17. The compound of claim 16, wherein A isselected from the group consisting of trimetazidine, etomoxir,perhexiline, a PPAR agonist, a malonyl CoA decarboxylase inhibitor, anddichloroacetate.
 18. The compound of claim 17, wherein A istrimetazidine.
 19. The compound of claim 16, wherein C is selected fromthe group consisting of nicotinic acid, nicotinamide, and nicotinamideribo side.
 20. The compound of claim 19, wherein C is nicotinic acid.21. The compound of claim 16, wherein L comprises (CH₂CH₂O)_(x), whereinx=1-15.
 22. The compound of claim 21, wherein A is trimetazidine. 23.The compound of claim 22, wherein the compound is represented formula(X):


24. A compound represented by formula (VI):

wherein: at least one of positions A, B, C, D, E, and F is substitutedwith —(CH₂CH₂O)_(n)H and n=1-15.
 25. The compound of claim 24, whereinposition F is substituted.
 26. The compound of claim 25, wherein thecompound is represented by formula (IX):


27. A method of treating a disease, disorder, or condition in a subject,the method comprising providing to the subject a compound represented byformula (VII):A-C  (VII), wherein: A comprises a compound that shifts cardiacmetabolism from fatty acid oxidation to glucose oxidation; and C is aNAD⁺ precursor molecule.
 28. The method of claim 27, wherein thedisease, disorder, or condition comprises impaired mitochondrialfunction or altered fatty acid oxidation.
 29. The method of claim 27,wherein the disease, disorder, or condition is selected from the groupconsisting of heart failure, ischemic heart disease, diabeticcardiomyopathy, rheumatic heart disease, valvular heart disease,aneurysm, atherosclerosis, high blood pressure, peripheral arterialdisease, angina, atherosclerosis, coronary artery disease, coronaryheart disease, heart attack, atherosclerosis, cerebral vascular disease,stroke, transient ischemic attacks, atherosclerosis, cardiomyopathy,pericardial disease, valvular heart disease, and congenital heartdisease.
 30. The method of claim 27, wherein C is covalently linked toA.
 31. The method of claim 30, wherein A is PEGylated with an ethyleneglycol moiety.
 32. The method of claim 31, wherein the ethylene glycolmoiety comprises (CH₂CH₂O)_(x), wherein x=1-15.
 33. The method of claim32, wherein the covalent linkage is via the ethylene glycol moiety. 34.The method of claim 32, wherein the covalent linkage is not via theethylene glycol moiety.
 35. The method of claim 27, wherein A isselected from the group consisting of trimetazidine, etomoxir,perhexiline, a PPAR agonist, a malonyl CoA decarboxylase inhibitor, anddichloroacetate.
 36. The method of claim 27, wherein C is selected fromthe group consisting of nicotinic acid, nicotinamide, and nicotinamideribo side.
 37. The method of claim 36, wherein C is nicotinic acid. 38.The method of claim 33, wherein the compound that shifts cardiacmetabolism from fatty acid oxidation to glucose oxidation is a PEGylatedform of trimetazidine.
 39. The method of claim 38, wherein C isnicotinic acid that is covalently linked to the PEGylated form oftrimetazidine.
 40. The method of claim 39, wherein the nicotinic acid iscovalently linked to the PEGylated form of trimetazidine via thePEGylated moiety.
 41. The method of claim 40, wherein the compound isrepresented by formula (X):


42. The method of claim 39, wherein the nicotinic acid is covalentlylinked to the PEGylated form of trimetazidine via the trimetazidinemoiety.
 43. The method of claim 27, wherein A is trimetazidine that iscovalently linked to C, which is nicotinic acid.
 44. A method oftreating a disease, disorder, or condition in a subject, the methodcomprising providing to the subject a compound represented by formula(VIII):A-L-C  (VIII), wherein: A is a compound that shifts cardiac metabolismfrom fatty acid oxidation to glucose oxidation; L is a linker; and C isa NAD⁺ precursor molecule.
 45. The method of claim 44, wherein thedisease, disorder, or condition comprises impaired mitochondrialfunction or altered fatty acid oxidation.
 46. The method of claim 44,wherein the disease, disorder, or condition is selected from the groupconsisting of heart failure, ischemic heart disease, diabeticcardiomyopathy, rheumatic heart disease, valvular heart disease,aneurysm, atherosclerosis, high blood pressure, peripheral arterialdisease, angina, atherosclerosis, coronary artery disease, coronaryheart disease, heart attack, atherosclerosis, cerebral vascular disease,stroke, transient ischemic attacks, atherosclerosis, cardiomyopathy,pericardial disease, valvular heart disease, and congenital heartdisease.
 47. The method of claim 44, wherein A is selected from thegroup consisting of trimetazidine, etomoxir, perhexiline, a PPARagonist, a malonyl CoA decarboxylase inhibitor, and dichloroacetate. 48.The method of claim 47, wherein A is trimetazidine.
 49. The method ofclaim 44, wherein C is selected from the group consisting of nicotinicacid, nicotinamide, and nicotinamide ribo side.
 50. The method of claim49, wherein C is nicotinic acid.
 51. The method of claim 44, wherein Lcomprises (CH₂CH₂O)_(x), wherein x=1-15.
 52. The method of claim 51,wherein A is trimetazidine.
 53. The method of claim 52, wherein thecompound is represented formula (X):


54. A method of treating a disease, disorder, or condition in a subject,the method comprising providing to the subject a compound represented byformula (VI):

wherein: at least one of positions A, B, C, D, E, and F is substitutedwith —(CH₂CH₂O)_(n)H and n=1-15.
 55. The method of claim 54, wherein thedisease, disorder, or condition comprises impaired mitochondrialfunction or altered fatty acid oxidation.
 56. The method of claim 54,wherein the disease, disorder, or condition is selected from the groupconsisting of heart failure, ischemic heart disease, diabeticcardiomyopathy, rheumatic heart disease, valvular heart disease,aneurysm, atherosclerosis, high blood pressure, peripheral arterialdisease, angina, atherosclerosis, coronary artery disease, coronaryheart disease, heart attack, atherosclerosis, cerebral vascular disease,stroke, transient ischemic attacks, atherosclerosis, cardiomyopathy,pericardial disease, valvular heart disease, and congenital heartdisease.
 57. The method of claim 54, wherein position F of the compoundis substituted.
 58. The method of claim 57, wherein the compound isrepresented by formula (IX):